
LIBRARY OF CONGRESS. 

Chapi/X-L-. Copyright No. 

Shelf„Ai.3-_6^ 



UNITED STATES OF AMERICA. 



THE 



SURGICAL COMPLICATIONS AND SEQUELS 
OF TYPHOID FEVER 






BY 

WILLIAM W< KEP:N, M.D., LL.D. 



PROFESSOR <>F THE PRINCIPLES OF SURGERY AND OF CLINICAL SURGERY, JEFFERSON MBDI- 

i A l i • ILLEGE, PHILADELPHIA; VI< B-PRBSIDENT OF THE COLLEGE OB PHYSICIANS 

OF PHILADELPHIA; MBMBRB CORRESPONDANT STRANGER DE LA 

SO< IBTB DE CHIRURGIB DB PARIS; MBMBRB HONORARIE 

DB I. A SOCIBTB BBLGB DB CHIRURGIB. 



BASED UPON TABLES OF 1700 CASES 

COMPILED KY THE AUTHOR AND BY 

THOMPSON S. WKSTCOTT, M.D. 

[NSTRU( rOR IN DISEASES OF CHILDREN, UNIVERSITY OF PENNSYLVANIA ; VISITING PHYSICIAN 
TO THE METHODIST EPISCOPAL HOSPITAL. PHILADELPHIA. 



A CHAPTER ON THE OCULAR COMPLICA- 
TIONS OF TYPHOID FEVER 

BY 

/ 

GEORGE E. de SCHWEINITZ, A.M., M.D. 

PROFESSOR OF OPHTHALMOLOGY, JEFFERSON MEDICAL COLLEGE ; PROFESSOR OF DLSEAS1 

OF THE EYE, PHILADELPHIA POLYCLINIC; OPHTHALMIC 5URGEON TO 

THE PHILADELPHIA AND ORTHOPEDIC HOSPITALS. 

AND AS AN APPENDIX 

THE TONER LECTURE, No. V. 



PHILADELPHIA 
W . B. SAUNDERS 

925 WALNUT STREET 
1898 




_ty_ TWO COMES RECEIVED 



*r±& 



Copyright, 1898, by W. B. Saunders. 



TABLE OF CONTENTS 



CHAPTER I. 
Introduction, 10 

CHAPTER II. 

Pathology of the Surgical Complications and Sequels 
of Typhoid Fever, 17 

CHAPTER III. 
Typhoid Gangrene, 52 

CHAPTER IV. 
Typhoid Affections of the Joints, 91 

CHAPTER V. 
Typhoid Affections of the Bones, 109 

CHAPTER VI. 
Typhoid Abscesses, 147 

CHAPTER VII. 
Typhoid Hematomata, 166 

CHAPTER VIII. 
Cfrep.ral Complications of Typhoid Fever, 169 

CHAPTER IX. 
Otitis Media in Typhoid Fever, 181 

CHAPTER X. 
Typhoid Parotitis, 1S3 

CHAPTER XI. 
Typhoid Affections of the Thyroid Gland, 186 

7 



8 TABLE OF CONTENTS. 

CHAPTER XII. 
Typhoid Affections of the Larynx, 188 

CHAPTER. XIII. 
Typhoid Affections of the Pleura, Lungs, and Heart, 199 

CHAPTER XIV. 
Typhoid Affections of the Esophagus and the Stomach, 202 

CHAPTER XV. 
Intestinal Perforation in Typhoid Fever, 212 

CHAPTER XVI. 
Typhoid Affections of the Liver and the Gall- 
bladder, 244 

CHAPTER XVII, 

Typhoid Affections of the Spleen, 274 

CHAPTER XVIII. 

Typhoid Affections of the Sexual Organs, 278 

I. Male, 278 

II. Female, 282 

CHAPTER XIX. 
Specific Mixed Infections in Typhoid Fever, .... 289 

Erysipelas, 289 

Tetanus, 294 

Anthrax, 294 

Malignant Edema, 295 

CHAPTER XX. 
Ocular Complications of Typhoid Fever, 296 

CHAPTER XXL 

LUSIONS, 314 

Appenlix : the Toner Lecture, ... 333 

Index, ^3 



LIST OF ILLUSTRATIONS. 

PAGE 

Plate I. Typhoid Bacilli in the Liver (Fraenkel and 

Simmonds), opposite 62 ' 

Plate II. Suppurative Typhoid Leptomeningitis (Ohl- 

macher), opposite 172 J 

Plate III. Necrosis of the Cricoid Cartilage (Fussell), 

opposite 194 ' 

Plates IV and V. Perforating Typhoid Ulcers of the 
Intestine (Museum of the Pennsylvania 
Hospital), opposite 216 v 

Fig. 1. "Shirt-stud Abscess" of Bone (Cornil and 

Pean), 135 

Fig. 2. Parotidean Sweating (Osier), 185 

Fig. 3. Typhoid Ulcers of the Stomach (Fenwick), . . 207 

Fig. 4. Typhoid Leukemic Spleen, 276 

TONER LECTURE. 

Fig. 1. Typhoid Necrosis of the Skull, 344 

Fig. 2. Typhoid Ulcer of Larynx, 349 

Fig. 3. Perichondritis Laryngea after Typhoid, . . 350 

Fig. 4. Perichondritis Laryngea after Typhoid, . . .351 

Fig. 5. Perichondritis Laryngea after Typhoid, . . . 352 



ERRATA. 
Page 40, line 3, for once read one. 
Page 74, line 8, for anus read arms ; line 9, for 20 cases read ^/ / line 13, for 

iji read 14J / line 14, dele and anus. 
Page 183, line 7, for j<5^ read jj - -?. 



SURGICAL COMPLICATIONS AND SEQUELS 



TYPHOID FEVER 



CHAPTER I. 
INTRODUCTION. 

The present monograph had its origin in two 
lectures. On February 17, 1876, I delivered the 
fifth Toner Lecture " On the Surgical Complications 
and Sequels of the Continued Fevers," which was 
published by the Smithsonian Institution in March, 
1877. On June 9, 1896, I delivered the Shattuck 
Lecture, before the Massachusetts Medical Society. 
In casting about for a subject for the latter lecture, 
it occurred to me that it would be just twenty years 
since my Toner Lecture, and that the literature 
accumulated on the subject during that period 
would well warrant a sequel, a sort of " Vingt ans 
aprcs." Accordingly, I asked Dr. Thompson S. 
Westcott to undertake the tabulation of the cases re- 
corded since 1876. They amount to over 900 cases. 

Not only did he tabulate the cases, but also ac- 
curately analyzed their results. That he has done 
his task with completeness and accuracy is evident 
in every chapter. It was evident that a single lecture 

1 1 



12 SURGERY OF TYPHOID FEVER. 

would not suffice for the discussion of so extensive 
a mass of material, and hence I restricted the Shat- 
tuck Lecture to "Gangrene as a Complication and 
Sequel of the Continued Fevers, Especially of 
Typhoid." (Trans. Mass. Med. Soc, 1896, and 
Boston Med. and Surg. Jour., July 2 and 9, 1896.) 
This Lecture I have made Chapter III in the 
present book, though much altered to fit it for its 
new place. 

I determined, therefore, at my earliest leisure, to 
take up the various other complications and sequels 
of typhoid, and so make as complete a monograph 
as possible. I was the more disposed to do so be- 
cause, though individual complications or sequels 
had been considered by various authors, no one 
since my previous attempt had treated the subject 
as a whole. 

I was also the more desirous of doing so because 
of the fact that the bacillus of typhoid had been 
discovered by Eberth in 1880, and hence our views 
of the pathology of these surgical lesions had under- 
gone a great and necessary change. Yet even now 
almost every chapter shows how deficient we are in 
precise knowledge of the exact nature of these 
lesions. Every case hereafter reported should be 
completed, if possible, by a bacteriological examina- 
tion. Negative evidence is as important as positive. 

How large a role the complications and sequels 
of typhoid play is well shown by the statement of 
Holscher (Miinch. med. Wochen., 1891, No. iv) that 
of the 2000 fatal cases there tabulated, only 24 per 
cent, died as a result of the typhoid infection per se, 
and 76 per cent, from the various medical and 
surgical complications and sequels. 



INTRODUCTION. 13 

The Toner Lecture and the present hook together 
cover 1 700 cases, and practically include nearly 
all the cases recorded in the last fifty years. The 
table ends with the literature of 1895, except a 
few important cases which have been reported after 
the table was completed and analyzed. The cases 
of Perforation of the Intestine (Chap. XV) and those 
of Perforation of the Gall-bladder (Chap. XVI) 
have been brought down to January, 1898. 

In the analysis of results (as to age, sex, location, 
etc.), unless otherwise stated the figures combine 
the results of the two series of cases of 1876 and 
1896. Single cases not seldom reappear in several 
chapters, since a case of gangrene might also suffer 
from a periostitis and a parotitis, and require to be 
considered under each heading. Such multiple le- 
sions are quite characteristic of typhoid. 

The diagnosis in a moderate number of cases is 
somewhat doubtful, but I have not felt at liberty to 
change it. The number of errors from this source, 
as well as those arising from the indefiniteness and 
meagerness of some of the histories, is not so great 
as to impair the substantial accuracy of the analyti- 
cal results, especially for clinical purposes. 

In the present book I have considered not only 
the six complications and sequels treated in the 
Toner Lecture, but I have added a formal chapter 
on the Pathology of the Surgical Affections of 
Typhoid, and also twelve chapters on other surgical 
affections of particular organs and regions. The 
surgical treatment of intestinal perforation did not 
exist in 1876. One of the principal additional chap- 
ters, from the practical standpoint, is upon this sub- 



14 SURGERY OF TYPHOID FEVER. 

ject. As this is so vitally important I have included 
a table of all the cases thus far reported. In con- 
nection with this chapter I wish to call especial atten- 
tion to the "conclusion" No. 10, formulated on 
page 318, that the essejttial mortality is not the 
mortality of the whole series (80.7 per cent.), but 
the mortality of those cases operated upon within 
the first twenty-four hours (69.4 per cent.), and that 
this will be further reduced when prompt surgical 
interference is the rule. In the chapter on Typhoid 
Affections of the Gall-bladder I have called attention 
to the propriety of immediate operation in peritonitis 
arising from similar perforations of the gall-bladder 
— a surgical chapter just opening. Four such cases 
have been operated upon with three recoveries. 

I have slightly changed the title of the present 
work both to distinguish it from my Toner Lecture 
and because nearly all of the cases in the second 
series are the surgical results of typhoid fever 
alone. In the first series of 785 cases (excluding 
352 of parotitis following typhus), 252 cases fol- 
lowed typhoid, 119 followed typhus, and 62 fol- 
lowed other continued fevers. In the second series, 
887 followed typhoid, only 23 cases followed typhus, 
while 4 followed other continued fevers. No better 
or more cheering evidence of the improved sanitation 
of the civilized world could be given than this palp- 
able diminution in the ravages of typhus fever. At 
the same time it is to be noted that these figures are 
to some extent deceptive. The unfortunate habit, 
especially of the Germans, of designating typhoid 
fever as " typhus abdominalis," and (from the far 
greater frequency of typhoid) the not infrequent use 



INTR ODUC TION. I 5 

of the word "typhus " alone, without the qualifying 

adjective, when typhoid was really the disease, makes 
the number of cases of typhus somewhat larger than 
it really is. Happily in the second series this is 
much less frequent. If a true typhus bacillus should 
be discovered, how will our German friends discrimi- 
nate between the two ? What endless confusion 
will arise ! — a confusion so easily avoided if the 
adjective "typhoid," or "enteric," were now used 
to designate the so-called " typhus abdominalis." 

The original tables on which my Toner Lecture 
was based unfortunately were not preserved. Hence 
in some of the analyses the later table alone has 
been available for points not covered by the earlier 
lecture. Where this is the case it is so stated. At 
first I had intended to publish also the tables and 
the bibliography in full, but this would have so in- 
creased the bulk and the cost of the book that I re- 
luctantly relinquished the idea. Instead of this I 
have given copious references. 

The ophthalmic lesions after typhoid are such a 
special class that I have asked my friend, Prof. 
George E. de Schweinitz, to write that chapter. 
The thoroughness and completeness of this chapter, 
like all his work, is very noteworthy. Both to him 
and to Dr. Westcott I desire to express my earnest 
thanks. I should also mention Profs. William H. 
Welch, William Osier, W. M. L. Coplin, and D. 
Braden Kyle, to whom I am indebted for valuable 
sueeestions and assistance. I also wish to acknow- 
ledge the courtesy of a number of gentlemen who 
have sent me notes of unpublished cases. 

In order to make the work as complete as pos- 



1 6 SURGERY OF TYPHOID FEVER. 

sible I have added, in a Postscript (page 321), a 
number of cases of importance which have appeared 
as die book has been passing through the press. 
They concern Chapters II, VIII, XVI, and XVII. 

I would be wanting both in courtesy as well as in 
gratitude did I not take this opportunity to express 
my obligation to the gentlemen in charge of the 
library of the Surgeon General's Office, U. S. A., 
for placing at my disposal both twenty years ago 
and now the treasures of that unrivalled collection. 
Without that, the Index Catalogue and the Index 
Medicus, it would have been practically impossible to 
make the work even approximately complete. The 
enlightened and liberal management of that library 
has made the whole world debtors to America, and 
it should receive even a far more generous support 
from the Government than it has had. 

My Toner Lecture was the first publication in 
which were gathered together the many surgical 
results of typhoid fever. Before its publication only 
single surgical lesions had been considered or 
sporadic cases had been published. Unfortunately, 
not having appeared in any of the medical journals, 
it never became well known to the profession. I 
have, therefore, with the kind permission of the 
Smithsonian Institution, republished it in the Ap- 
pendix. 



CHAPTER II. 

PATHOLOGY OF THE SURGICAL COMPLICATIONS AND 
SEQUELS OF TYPHOID FEVER. 

The province of the physician and that of the sur- 
geon are, in general, sufficiently sharply defined and 
differentiated, yet they have many points of contact. 
While some diseases belong exclusively to the prov- 
ince of the one and some to that of the other, other 
diseases may fall with equal propriety under the care 
of either practitioner. Still another class of cases, 
however, beginning in the domain of medicine may 
terminate in that of surgery, and we may lack their 
complete history from the very fact of this division 
of their care and interest. 

Among the diseases classed as strictly medical, 
none deserve the appellation more definitely than 
the continued fevers, and especially typhoid fever. 
Yet the present work shows that these fevers are 
not infrequently the cause of the gravest and least 
expected surgical troubles, mention of which is gen- 
erally omitted, even in our best text-books on medi- 
cine, still more rarely noticed in works on surgery, 
and, where noticed, it is only with the greatest 
brevity. 

The surgical results of scarlet fever and the other 
exanthemata have loner been recognized and de- 
scribed. But up to 1876, when I published my 
Toner Lecture, surgical troubles after typhoid 

17 



1 8 SURGERY OF TYPHOID FEVER. 

and other continued fevers were deemed rather 
among the curiosities of literature, than looked upon 
as somewhat rare, but yet well-ascertained surgical 
post-febrile lesions, which should be expected from 
time to time and, therefore, watched for and, if pos- 
sible, prevented. Since 1880, when Eberth discov- 
ered the bacillus of typhoid fever, our views of the 
pathology not only of the fever itself, but also of its 
complications and sequels, recent and remote, have 
undergone an entire revolution and we now under- 
stand much that was formerly inexplicable. 

I shall only consider the pathology of typhoid 
sufficiently for us to see its bearing from the surgical 
side ; more than that would be out of place. The 
pathology of typhus fever is so much less clear and 
certain, and the number of cases after typhus so 
much smaller, especially at the present time, that I 
shall entirely omit its special consideration. 

In order to gain a clear idea of the pathology of 
typhoid and post-typhoid lesions, I will consider : 

1 . The viability of the typhoid bacilli both in and 
out of the body ; and, therefore, the possibility of 
their causing late as well as early sequels of the 
fever. 

2. Their wide diffusion in the various organs of 
the human body, and, therefore, the possibility, if not 
the probability, that all the various surgical results 
may be caused by them. 

3. Mixed infections of the typhoid bacilli with 
other bacteria. 

4. The pyogenic faculty of the typhoid bacilli. 

5. Typhoid infection of different organs without 
typical typhoid lesions in the intestine. 



PATHOLOGY. 19 

I. The Viability of the Typhoid Bacilli (a) 
Outside the Human Body. — In favorable condi- 
tions — e. £: in a bacteriological laboratory — the 

typhoid germs may live indefinitely : but in unfavor- 
able conditions, also, their viability is remarkable. 
Thus Losener ' found that the bacillus only disap- 
peared from the body ninety-six days after burial. In 
feces they may live even for months. 2 Remlinger and 
Schneider 3 have found them in the feces of five out 
often patients who had never had typhoid fever. 

Schiller 4 impregnated threads with the bacillus, and 
found them still active in periods of from one to two 
years. 

Uffelmann 5 found them still living and active after 
eighty-two days in dry sterile sand. 

(6) Their Viability Inside the Human Body. 6 
— I will not mention instances, of which there are a 
large number, in which the typhoid bacilli have 
been found in abscesses, etc., within three or four 
weeks after the fever, but only those cases in which 
they have been found months and even years after- 
ward. 

By far the longest time after the fever, when the 

1 Arbeit, kaiserlich. Gesundheitsamte, 1895. 

2 Ziegler, Allgem. Pathol., 1895, i, 597. 

;i Ann. de PInstitut Pasteur, 1897, xi, 55. 

4 Arbeit, kaiserlich. Gesundheitsamte, v, 312. 

5 Centralbl. f. Bakteriol., 1894, Nos. 5 and 6. 

6 Schniizler, Centralbl. f. Bakteriol. und Parasitenk., 1894, 270, in a case 
of old osteomyelitis, found the staphylococcus pyogenes aureus after thirty- 
five years, and Krause, Fortschritte d. Med., ii, Nos. 7 and 8, found the same 
organism after thirty years. Both these, however, may have resulted from a 
continuous or a late re-infection. I merely mention them as instances of the 
extreme viability of these organisms also in the human body. 



20 SURGERY OF TYPHOID FEVER. 

typhoid bacillus has been found, and in pure culture, 
is that of von Dungern. 1 Fourteen vears and a 
half after the fever the bacillus was found in an 
abscess about the gall-bladder. A resume of the 
case is given in Chapter XVI. 

Buschke 2 reports the case of a woman of sixty- 
six who fell ill of typhoid in October, 1886. Before 
Christmas, when she left her bed, she complained 
of swelling, pain, and tenderness in the fifth and 
sixth ribs and cartilages on the right side. The 
pain and tenderness subsided, but the swelling did 
not disappear. In December, 1893, without any 
evidence of a re-infection, the pain returned, but 
again subsided only to recur for a third time. On 
her admission to the hospital February 19, 1894, 
below and to the inside of the right breast was a 
swelling the size of a hen's egg, soft and fluctuating 
in parts. In the axilla was an enlarged gland. On 
February 26th the swelling was incised, the pus 
evacuated, and the granulation tissue curetted. A 
pure culture of the typhoid bacillus was found in the 
pus. Hence over seven years after the fever the 
bacilli had retained their vitality and their virulence, 
as was shown not only by the abscess in the patient, 
but by experiment. Bouillon cultures of these 
bacilli were injected into rabbits. These rabbits, it 
is true, remained well, but from the places where the 
injections were made new cultures were taken, with 
every antiseptic precaution, and these injected in 
other rabbits proved fatal, and from their dead 

1 Munch, med. Wochen., 1897, No. 26, p. 699. 

2 Lebensdauer d. Typhusbacillen in ostitischen Herden, Fortschritte d. 
Med., 1894, 573- 



/'A 77/0 LOGY. 21 

bodies the typhoid bacillus was obtained, thus com- 
pleting the circle of proof. 

Bruni ' records the case of a woman of thirty-six 
who, in 1889, during- convalescence, developed an 
osteoperiostitis of the right femur with tenderness 
over the left tibia. Six years later an osteomyelitis 
developed in the latter bone. The tibia was tre- 
phined, and from the pus in the medullary cavity 
typhoid bacilli were obtained and their virulence es- 
tablished by inoculation. 

The next longest case on record -is that of Sultan. 2 
For six years after the fever the patient had had a 
fistulous openingleadingdown to the clavicle. Though 
an infection with the ordinary pyogenic or other 
extraneous bacteria would seem to be inevitable in a 
case of open suppuration extending over so long a 
period, the discharge showed a pure culture of the 
typhoid bacillus. Chantemesse 3 has described a 
case with abscesses in the right tibia, left femur, left 
ulna, and a left finger in which a pure culture of the 
typhoid bacillus was found after four years. 

In addition to these extraordinary cases, the fol- 
lowing authors have found the bacilli, usually in pure 
culture, after long periods. Parsons 4 reports a pure 
culture in the case of a sinus open and discharging 
for three months ; Pean and Cornil, 5 in a tibial peri- 
ostitis and abscess after eight months ; Chantemesse, 6 
in a similar case, after six and a half months, and in 

1 Ann. de 1' Institul Pasteur, 1896, x, 220. 

2 Deutsch. med. Wochen., 1894, 675. 

3 Bull, et Mem. Soc. Med. des Hop., 1893, x > 779- 

4 Johns Hopkins Hosp. Reports, v, 417. 

5 Bull. Acad. Med., Paris, 1891, 3d series, xxv, 599. 

6 Bull, et Mem. Soc. Med. des Hop., 1893, x > 779- 



22 SURGERY OF TYPHOID FEVER. 

another after eleven months ; Chantemesse and 
Widal, 1 in an abscess after fifteen months; Orloff, 2 
in a case of periostitis after eight months ; Klemm, 3 
in an osteomyelitis after a year ; Chantemesse and 
Widal, 4 after eighteen months ; Werth, 5 in an ova- 
rian cyst after eight months ; Berg, 6 in a case of 
chondritis of the costal cartilages after three years ; 
Lockwood, 7 in a tibial abscess after fifteen months ; 
Hintze, 8 in a " cold " periosteal abscess after ten 
months ; Fraenkel, 9 in a pleural effusion after five 
months, and in an abdominal abscess IO after four 
and a half months. 

Of course, in many cases the typhoid bacilli have 
not been found. Thus, Schede IT was unable to find 
them in ten cases of abscess of bone. All were due 
to the pyogenic bacteria. But such cases, however 
numerous they might be, could not change the facts 
above cited in which there is positive and cumulative 
proof of the long-continued vitality and virulence of 
the typhoid bacilli in various tissues, but especially 
in the bones. That they may be, and not only may 
be but certainly are. responsible for the mischief in 
the midst of which they were found, even though it 
be lono- after the fever, is a most reasonable conclu- 
sion. This is rendered still more certain by the 
experimental proof of the pyogenic power of the 
typhoid bacilli shortly to be given (p. 40). 

1 Traite de Med., July, 1S91, i. 2 Deutsch. med.Wochen., 1S90, p. 1806. 
3 Arch. klin. Chir., 1893, xlvi > 86:! - 4 Sem - M6d > l8 93> 542- 

5 Deutsch. med. Wochen., 1893, No. 21. 

6 Centralbl. f. Chir., 1896, 153. 

7 Lancet, 1895, i. 531. s Centralbl. f. Bakteriol., Oct. 10, 1893, 445. 
9 Buschke, /or. a'/., 581. 10 Deutsch. med. Wochen., 1894, p. 152. 

1 J Munch, med. Wochen., 1888, No. II. 



PATHOLOGY. 23 

II. The Wide Diffusion of the Typhoid 
Bacilli in Various Organs and Tissues of 
the Body. — Scarcely a single tissue or organ of the 
body escapes invasion by the typhoid bacilli. Not 
only the normal tissues are invaded, but, as is seen 
by the preceding section and in many later chapters, 
they are found in the pus of abscesses in every 
region of the body and in empyema, in the effusion 
of teno-synovitis, in the non-purulent fluid of orchitis, 
etc. Among" the various tissues and organs in which 
the bacilli have been found are the following: 

1. The Blood. — The bacilli of typhoid are not com- 
monly found in the blood. When present, they are 
most numerous in the first twelve days of the dis- 
ease. From then until the end of the third week they 
diminish rapidly, and during the fifth and sixth weeks 
are only found exceptionally (Park). It is probable 
that they reach the blood by the lymphatics, since they 
are found in abundance in the thoracic duct. 1 That 
they must be distributed to other parts of the body 
(vide infra) by the blood (though so rarely actually 
found there) is made probable also by the fact that 
not rarely they are found in multiple organs of the 
body which could only be reached through the circula 
tion. This is strikingly shown in the remarkably well- 
studied cases of Flexner, 2 in which he found them in 
the mesenteric glands, the spleen, the liver, the bile, 
the kidneys, the lungs, the marrow of the bone, and 
in the blood of the heart. In the kidneys there were a 
large number of abscesses resembling miliary tuber- 

1 Dehu, Le role du bacille d'Eberth dans les complications de la fie v re 
typboide, These de Paris, 1893. p. 59. 

2 Jour, of Pathol, and Bacterid., 1894, iii, 202. 



24 SURGERY 01 TYPHOID FEVER. 

cle, which, however, were proved to be real abscesses 
containing the bacillus of typhoid in pure culture. 

Vincent l also gives details of six cases in which 
they were found in the blood, the spleen, the liver, 
the mesenteric glands, the brain, the spinal cord, the 
cerebrospinal fluid, the kidneys, and the lungs. 

Neuhauss, 2 Rutimeyer, 3 Achalme, 4 Klihnan, 5 Ander- 
son, 6 Guarnieri, 7 and Block 8 have also found them 
in the blood, and in some instances proved their 
activity by injection into animals. 

Kanthack and Tickell 9 and Ohlmacher 10 have 
found them in the blood in mixed infection with 
the streptococcus. 

That they must exist in the blood and be diffused 
by it is also proved by several cases in which the 
fever, having caused the patient to abort, the bacillus 
of Eberth has been found in the placenta and the 
fetus (p. 32). In these cases no other route for the 
infection is possible. Chantemesse and Widal IX also 
found the bacilli in large quantities in the fetus and 
the amniotic fluid of the cobaye. 

2. In the endocardium and endocardial vegetations. 

3. In the walls of the arteries and the veins, pro- 
ducing arteritis and peri-arteritis, phlebitis and peri- 
phlebitis. 

1 Ann. de l'lnstitut Pasteur, 1893, vii, 141. 

2 Berlin, klin. Wochen., 1886, Nos. 6 and 24. 

3 Centralbl. f. klin. Med., 1887, No. 9. 

1 Comptes Rendus Soc. de Biol., June 21, 1890. 

5 Berlin, klin. Wochen., June 23,1896. 

6 Med. News, Aug. 8, 1896, 155. T Revist. Gen. Clin. Med., 1892, 234. 

8 Johns Hopkins Hosp. Rep., June, 1897. 

9 Edinb. Med. Jour., July, 1897, 22. 

10 Cleveland Med. Gaz., May, 1897. 

11 Gaz. Ilebdom., March 4, 1887, 146. 



PATHOLOGY. 25 

4. In thrombi in the heart arteries and veins. 

These three are considered more fully in Chap- 
ter III, on Gangrene, since they bear especially upon 
that process. 

5. In the muscles they have been found by (Nas- 
ser, 1 Raymond, 2 Rosin and Hirschel, 3 Jahradnicky. 4 

6. In the Connective Tissues. — There are only three 
cases in our table in which a bacteriological exami- 
nation has been made. In Vincent's case 5 the 
typhoid bacilli were found in the cardiac vegetations 
and the blood in the heart, in the spleen, kidney, brain, 
bone-marrow, etc., but no observations were made 
as to the muscular hematoma. In Lockwood's, 6 the 
pus of an abscess over the tibia contained only the 
bacilli of Eberth fifteen months after the fever. 

Raymond, 7 in 1890, after a careful examination by 
Strauss, reported that the bacillus of Eberth was 
found in pure culture. Among other such muscular 
cases are those of Swiczinki 8 and Tinctine. 9 

7. Skin. — Most of the infections of the skin are 
probably pyogenic, but Rheiner 10 has found the 
typhoid bacillus in the skin in cases of post-typhoid 
erysipelas. See also Valentini " and Raymond 12 for 
other facts. Sittmann I3 records a curious case of a 
suppurating lipoma of the skin of the knee in which 
the typhoid bacillus was found in pure culture. 

1 Pein, L' Action pyogenique du bacille typhique, p. 88. 2 Ibid. , p. 58. 
3 Deutsch. med. Wochen., 1892, No. 22. 4 Centralbl. f. Chir., 1896, 336. 
5 Merc. Med., Feb. 17, 1S92, p. 73. 6 Lancet, 1895, i, 531. 

7 Pein, These de Paris, 1S91, p. 58. s Chronica Lekarska, 1894, No. 8. 
9 Arch, de Med. Exp. et d'Anat. Pathol., 1S94, vi, 1. 

10 Arch. f. Path. Anat., 18S5, c, 1S5. 

11 Berlin, klin. Wochen., 1889, No. 17. 

12 Gaz. Med. de Paris, 1891, No. 9. 

13 Deutsch. Archiv f. klin. Med., liii, 1894, 352. 



26 SURGERY OF TYPHOID FEVER. 

8. Synovial sheaths of tendons at ankle. Grancher 1 
reports the only case I have found. 

9. Joints. — In Chapter IV I have given the results 
of all the bacteriological examinations I have myself 
made or found recorded. They are all negative so 
far as finding the typhoid bacillus, except that they 
were once recorded as present soon after experi- 
mental inoculation into the joints. 

10. Bones. — Very many observers, as indicated in 
Chapter V, have found the bacilli in the marrow of 
the bones, where they have remained for a greater or 
less time without producing disease. Usually these 
cases have been observed either at post-mortem 
examinations or in experimental researches. In 
other cases the bacilli have been found in periostitis, 
abscess, osteomyelitis, etc. I do not pretend to give 
a complete list, but among them may be named : 



Ebermeier, Deutsch. Arch. f. klin. Med., 1 
xliv, 140. 

Flexner, Jour, of Pathol, and Bacterid., Nov., 1894, 
iii, 202. 

Orloff, Wratsch, 1889, No. 49, and 1890, Nos. 4, 
5, and 6. 

Valentini, Berlin, klin. Wochen., 1889, No. 17, 368. 

Achalme, Comptes Rendus Soc. de Biol., June 21, 
1890, 387. 

Chantemesse and Widal, Arch, de Physiol., 1887. 

Chantemesse, Bull, et Mem. Soc. Med. des Hop., 
1890, vii, 655; 1893, x, 779. 

Bauer, Centralbl. f. Chir., 1895, 788. 

Colzi, Lo Sperimentale, lxv, 1890, 623. 

Melchior, Jahresbericht Fortschritte Pathol. Mik- 



roorgan., Band viii. 



Bull. Med., 1892, vi, 1271. 



PATHOLOGY. 27 

Dupraz, Arch. Med. et Anat. Pathol., Jan. 1, 1892, 
76. 

Buschke, Fortschritte d. Med., 1894, 573. 

Sultan, Deutsch. med. Wochen., 1894, 675. 

Parsons, Johns Hopkins Hospital Rep., v, 417. 

Gilbert and Girode, Comptes Rendus Soc. de 
Biol., July 11, 1890, and May 2, 1891. 

Klemm, Arch. f. klin. Chir., 1893, xlvi, 862 ; xlviii, 
792. 

Pean and Cornil, Bull. Acad, de Med., 189 1, 3d 
series, xxv, 599. 

Quincke, Berlin, klin. Wochen., 1894, No. 15. 

Hintze, Centralbl. f. Bakteriol., 1893, 445. 

Helferich, Berlin, klin. Wochen., 1890, 979. 

Vincent, Merc. Med., Feb. 17, 1892, y^. 

Berg, Centralbl. f. Chir., 1896, 153. 

Rosin and Hirschel, Deutsch. med. Wochen., 1892, 

493- 

Welch, N. Y. Med. Record, 1893, i, 631. 
Barbacci, Lo Sperimentale, 1891, 356. 
Mouisset, Lyon Med., 1891, 326. 

11. In the brain and spinal cord (meningitis, ab- 
scess, etc.): 

Ohlmacher, Jour, of Amer. Med. Assoc, Aug. 28, 
1897, xxix, 419. 

Kamen, Internat. klin. Rundschau, 1890, Nos. 3 
and 4. 

Neumann and SchaefTer, Virchow's Archiv, 1887, 
cix, 480. 

Honl, Centralbl. f. Bakteriol. unci Parasitenk., xiv, 

767. 

Adenot, Lyon Med., 1889. Nos. 34 and 36, and 
Arch, de Med. Exp. et d'Anat. Pathol., 1889, 

No. 5. 

Hintze, Centralbl. f. Bakteriol., Oct. 10, 1893, 445. 
Mensi and Carbone, Riforma Med., 1893, No. 2. 
Silva, Riforma Med., 1891. 



28 SURGERY OF TYPHOID FEVER. 

Vincent, Merc. Med., Feb. 17, 1892, p. 73. 
Tinctine, Arch, de Med. Exp. et d'Anat. Pathol., 

1894, vi, 1. 

Fernet, Bull. Soc. des Hop., 1891, No. 23, 361. 

Dadcli, Lo Sperimentale, 1894, No. 17, 325. 

Balp, Revist. Gen. Ital. Clin. Med., 1890, No. 17, 
406. 

Chantemesse and Widal, Gaz. Hebdom., 1887, 
146. 

Curschman, Verhandl. Kongress f. inner. Medizin, 
1886, 469. 

Kiihnan, Berlin, klin. Wochen., 1896, June 23d. 

12. In the thyroid gland : 

Colzi, Revist. Gen. Clin. Med., 1891, No. 10, and 
Lo Sperimentale, 1891, No. 2. 

Honl, Centralbl. f. Bakteriol. und Parasitenk., xiv, 
767. 

Jeansalme, Arch. Gen., 1893. 

Spirig, Correspondenzbl. schweiz. Aerzte, Feb. 
15, 1891. 

Dupraz, Arch, de Med. Exp. et d'Anat. Pathol., 
Jan. 1, 1892, p. y6. 

Kutnmer and Tavel, Rev. de Chir., June, 1891, 
and Aetiol. d. Strumitis, Basel, 1892. 

13. In the orbit : 

Panas, Cinquieme Congres de Chir., March 30, 
1891. 

1 4. In the parotid gland : 

Lehmann, Centralbl. f. klin. Med., Aug., 1891, 649. 
Janowski, Centralbl. f. Bakteriol. und Parasitenk., 

1895, xvii, 785. 

15. In otitis media : 

Destree, Jour. Med. Brux., xcii, Aug. 15th. 
Vincent, Ann. de 1'Institut Pasteur, Paris, 1893. 



PATHOLOGY. 29 

16. In the heart=muscle : 

Chantemesse andWidal, Gaz. Hebdom., i <S ( S 7 , 146. 
I 7. In the lungs : 

Flexner, Jour. Path, and Bacteriol., Nov., 1894, iii, 
206. 

18. In the pleura (empyema, etc.): 

Charrin, Soc. Med. des Hop., March 17, 1891. 
Infection of the pleuritic fluid with the typhoid bacil- 
lus, but no intestinal lesions of typhoid. 

Fernet, Bull. Soc. Med. Hop., 1891, May 21, 236. 

Loriga and Pensuti, Riforma Med., 1890, 1232. 

Valentini, Berlin, klin. Wochen., 1889, 368. 

Spirig, Mittheil. aus klin. und med. Instit. d. 
Schweiz, Basel, 1893-94, 771. 

Kelsch, Merc. Med., March 2, 1892, p. 97. 

Weintraud, Berlin, klin. Wochen., 1893, xxx, 345. 

Rendu and de Gennes, La France Med., 1885, 
ii, 1821. 

Belfanti, Revist. Gen. Ital. de Clin. Med., 1890, 
No. 20. 

Foa and Bordoni-Uffreduzzi, Riforma Med., iSSj, 
No. 1. 

Burci, Arch. Ital. clin. Med., 1893, xxxii, 1. 

Arustamoff, Centralbl. f. Bakteriol. und Parasitenk., 
vi, 1889. 

19. In the peritoneum : 

Fraenkel, Sem. Med., April 27, 1887. 

Lehmann, Centralbl. f. klin. Med., Aug., 1891, 649. 

Raymond, Sem. Med., 1891. 

Fraenkel, Deutsch. med. Wochen., 1894, 152. 

20. In the liver : 

Guarnieri, Revist. Gen. Clin. Med., 1892, 234. 
Chantemesse and Widal, Gaz. Hebdom., 1887, 146. 
Chantemesse, Bull, et Mem. Soc. Med. des Hop., 
1893, x, 779. 



30 SURGERY OF TYPHOID FEVER. 

Cygnaus, Ziegler's Beitrage, etc., 1890, vii. 
Flexner, Jour. Path, and Bacterid. , Nov., 1894, iii, 
202. 

Lannois, Rev. de Med., 1895, No. n, 909. 

Vincent, Merc. Med., Feb. 17, 1892, 73- 

Rosin and Hirschel, Deutsch. med. Wochen., 1892, 

Gaffky, Mitth. kaiser. Gesundheitsamte, ii, 1884. 
Fraenkel and Simmonds, Die aetiolocr Bedeut. d. 
Typhusbacillen, Leipzig, 1886. 

21. In the gall=bladder and bile : 

Von Dungern, Munch, med. Wochen., 1897, No. 26. 

Osier, see Chapter XVI. 

Chantemesse, Traite de Med., i, 764. 

Mason, Boston Med. and Surg. Jour., May 13, 
1897, and Trans. Assoc. Amer. Phys., 1897. 

Gilbert and Girode, Sem. Med., 1890, No. 58, 
and Mem. Soc. Biol, 1893, 956. 

Chiari, Prag. med. Wochen., 1893, No. 22, 261. 

Dupre, Les Infections Biliaires, These de Paris, 
1891. 

Fournier, These de Paris, 1896. 

Salzmann, Wiirttemb. med. Correspondenzbl., 
1870, p. 84. 

Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, 
iii, 202. 

Welch, Johns Hopkins Hosp. Bull., Aug., 1891, 
No. 15, 121. 

Blackstein, Johns Hopkins Hosp. Bull., No. 14, p. 
96. 

Alexieef, Amer. Jour. Med. Sci., Oct., 1897, 466. 

22. In the spleen : 

Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, 
iii, 202. 

Ohlmacher, Jour. Amer. Med. Assoc, August 28, 
1 897, xxix, 419. 



PATHOLOGY. 31 

Kanthack and Tickell, Edinb. Med. Jour., July, 
1897, 22. 

Vincent, Merc. Med., Feb. 17, 1892, 73. 

Roux and Vinay, Lyon Med., June 10, 1888. 

Neuhauss, Berl. klin. Wochen., 1886. 

Chantemesse and Widal, Gaz. Hebdom., 1887, 
146. 

Ebermeier, Deutsch. Arch. f. klin. Med., 1889, xliv, 
140. 

Laveran, Bull. Soc. Med. des Hop., 3d series, vol. 
viii, p. 90. 

Haushalter, Merc. Med., Sept. 20, 1893, 453. 

Klihnan, Berl. klin. Wochen., June 23, 1896. 

Guarnieri, Revist. Gen. Clin. Med., 1892, 234. 

23. In the mesenteric glands : 

Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, 
iii, 202. 

Ohlmacher, Jour. Amer. Med. Assoc, August 28, 
1897, xxix, 419. 

Lehmann, Centralbl. f. klin. Med., August, 1891, 
649. 

Fraenkel, Sem. Med., 1887, l 73- 

Vincent, Merc. Med., Feb. 17, 1892, 73. 

Gilbert and Girode, Comptes Rendus Soc. Biol., 
May 2, 1 89 1. 

Klihnan, Berl. klin. Wochen., June 23, 1896. 

24. In the kidney : 

Flexner, Jour. Pathol, and Bacteriol., Nov., 1894, 
iii, 202. 

Faulhaber, Beitr. path. Anat. und allg. Path., x. 

Koujojeff, Centralbl. f. Bacteriol. und Parasitenk., 
1889. 

Vincent, Merc. Med., Feb. 17, 1892, y^>- 

Von Wunscheim, Prag. med. Wochen., xliv, 1894. 

Seitz, Centralbl. f. Bakteriol., ii, 1887. 

Neumann, Berlin, klin. Wochen., 1890. 



32 SURGERY OF TYPHOID FEVER. 

25. In the urine : 

Bouchard, Rev. de Med., 1881, 671. 

Kanthack and Tickell, Edinb. Med. Jour., July, 
1897, 22. 

Wissokowitsch, Zeitschr. f. Hyg., vol. i, p. 1. 

Seitz, Bakteriol. Studien z. Typhusaetiologie, 
1886. 

Hueppe, Fortschritte d. Med., 1886, 447. 

KoujojefT, Centralbl. f. Bakteriol. u. Parasitenk., 
1889, vi, 24. 

Neumann, Berlin, klin. Wochen., 1888, No. 7, 1890, 
No. 6. 

Faulhaber, Ziegler's Beitr. path. Anat. u. allg. 
Pathol., x, 1891. 

Karlinski, Prag. med. Wochen., 1890, xv, 437. 

26. In the ovary : 

Werth, Deutsch. med. Wochen., 1893, No. 21. 
Sadeck, Munch, med. Wochen., 1896, No. 21. 

27. In the testicle and epididymis : 

Girode, Arch. Gen., 1892, i, clxix, 43. 

Tavel, Correspondenzbl. schweiz. Aerzte, 1887, 

590. 

Gasser, Arch, de Med. et de Pharm. Milit., 1895, 
No. 3, 228. 

Menetrier in Pein, These de Paris, 1890, p. 18. 

Belfanti, Revist. Gen. Ital. Clin. Med., 1890, No. 
20. 

28. In the placenta and fetus : 

Wiclal and Chantemesse, Gaz. Hebdom., March 4, 
1887, 146. 

Hildebrand, Fortschritte d. Med., 1889, vii, 889. 

Eberth, Fortschritte d. Med., 1889, vii, No. 5. 

Ernst, Beitr. path. Anat. u. allg. Path., 1890, 
viii, p. 1. 

PLtienne, Gaz. Hebdom., 1896, No. 16. 

Janizewski, Munch, med. Wochen., 1893. 



PATHOLOUW 33 

Frascanni, Jahresb. Fortsch. Path. Microorganism., 

1892. 

Neuhauss, Berl. klin. Wochen., 1886. 

Reher, Arch. Exp. Pathol, et Pharmacol., xx, 420. 

Giglio, Centralbl. f. Gynekol., 1890, No. 46. ' 

Griffith 2 reports an interesting case of a child 
born at full term while the mother was still ill of 
typhoid fever. The attack was light, the rose spots 
appeared on November 13th, and the child was born 
on the 1 8th. When the child was seven weeks old 
it responded to Widal's test. He concludes that 
the child had had an attack of the fever in utero. 

A still more remarkable case is reported by 
Etienne. 3 He examined a five months fetus born of 
a mother aged eighteen, on the twenty-ninth day 
of typhoid. "The child's spleen and intestines, as 
well as other organs, showed no evidence of the dis- 
ease, and the placenta was healthy. Blood from the 
right side of the heart and from the spleen, liver, 
and placenta was carefully examined and cultures 
made. ' The typhoid bacillus was found in abun- 
dance. The fetus had really died of typical acute 
blood-poisoning from a large dose of the bacillus 
before the occurrence of anv local chancre." 

III. Mixed Infection of the Typhoid Bacillus 
and the Pyogenic and Other Bacteria. — Very 
rarely specific infections, such as those of tetanus, 
erysipelas, anthrax, and malignant edema, occur in 

1 In this bibliography I have been materially assisted by Flexner's paper, 
Ziegler's allgemein. Pathol., Dmochowski and Janowski's, and Rosin and 
Hirschel's papers. 

2 Med. News, May 15, 1897. 

3 Brit. Med. Jour., Epitome 1896, ii, 35, from the Gaz. Hebdom., 1896, 
No. 16. 



34 SURGERY OF TYPHOID FEVER. 

cases of typhoid fever. These mixed infections are 
considered in Chapter XIX. In this section I shall 
only review the relation of the typhoid and the 
pyogenic bacteria. The subject can not be sharply 
separated from that of the next section — cases of 
suppuration caused by the typhoid bacillus in pure 
culture — but will well lead up to it. 

Many authors, especially those who made the 
earlier bacteriological examinations, disbelieved ab- 
solutely — and very naturally — in the pyogenic prop- 
erties of the typhoid bacillus. They ascribed all 
suppurative lesions during or following the fever to 
an infection by the pyogenic bacteria alone or to 
a superadded or secondary infection by the pyo- 
genic bacteria in addition to that by the typhoid 
bacillus. 

Many surgical affections during and after typhoid 
are undoubtedly almost constantly purely pyogenic. 
For example, otitis media almost always results, so 
far as we know, from pyogenic bacteria ; parotitis in 
the great majority, and the same is true of abscesses, 
etc. In many cases even of disease of the bones 
this is equally the fact— e. g., Schede x in ten cases 
of abscess of bones found only the pyogenic bacteria, 
and Dunin 2 found the same bacteria in eight cases 
of lesions of bones. 

Nay, more than this, the pyogenic infection may, 
though very rarely, result in distinct pyemia or sep- 
ticemia in which the typhoid bacilli play no part 
whatever. Thus one case reported by Wagner 3 com- 



1 Munch, med. Wochen., 1888, No. II. 

2 Deutich. Arch. f. klin. Med., 1886, xxxix, 369. 
8 British Med. Jour., 1891, i, 18. 



PATHOLOGY. 35 

menced with a crural phlebitis relatively early in the 
disease (the ninth day), death occurring from pyemia 

on the eighteenth day. In another, reported by 
Spilhnan, 1 gangrene of the lips occurred, probably 
due to carious teeth, and the patient died from staphy- 
lococcus septicemia, the aureus being found in the 
spleen, kidneys, and liver. It had probably obtained 
entrance from the mouth and set up a secondary 
systemic infection during convalescence as the earlier 
infection was disappearing. Rendu 2 reports another 
case with purulent arthritis of the right hip-joint, 
abscesses of the right thigh, and osteomyelitis, puru- 
lent pleuropneumonia, and nephritis. Julliard 3 re- 
ports a case of septicemia following a typhoid 
hemorrhage in the neck. 

That mixed infection should occur in typhoid fever 
is not at all remarkable, since the intestinal ulcers 
and, in a large minority of the cases also, the ulcera- 
tion of the mucous membrane of the mouth, and the 
bedsores which are so frequent in typhoid, afford 
favorable ports of entry. 4 

Mixed infections, by co-existing pyogenic and 
typhoid bacteria, as would be expected, are not un- 
commonly met with. Thus Lehmann 5 reports a fatal 
case of encapsulated peritoneal abscess and sup- 
purative parotitis, and in the parotid was found a 
mixed culture of the Eberth bacillus and the staphy- 
lococcus. 

1 Merc. Med., 1S95, No. 13, 145. 

2 Witzel, Gelenk- u. Knochenkrankh. 

3 Guyot, Etude sur 1' Hematocele periuterine, etc., dans la Fievre 
Typhoide, These de Paris, 1879. 

4 See Introduction for a fullerMiscussion of these points. 

5 Centralbl. f. klin. Med., 1891, 649. 



36 SURGERY OF TYPHOID FEVER. 

Spirig * records a case of suppuration in the thy- 
roid with a mixed culture of the typhoid bacillus and 
the staphylococcus albus, and Parsons 2 records a case 
of osteomyelitis and necrosis of the left radius in 
which the citreus and the typhoid bacillus co-existed, 
while the aureus alone caused a suppurative periosti- 
tis of the right tibia. Rendu 3 found, in the pus of a 
typhoid empyema, both the pyogenic and the typhoid 
bacteria. 

In a few cases a mixed infection occurs in which 
the typhoid bacillus exists in one place and a pyo- 
genic organism in another. Thus Laveran 4 records 
a case of abscesses on the dorsum of the ripfht hand, 
right arm, and left forearm in which the staphylococ- 
cus only was found in these abscesses with great 
numbers of the typhoid bacilli in the spleen. Flex- 
ner 5 reports a case of very wide diffusion of the 
typhoid bacilli in other organs, but in the parotid gland 
only the streptococcus was found. 

It has been suggested that those cases in which 

be) 

suppuration occurred and the typhoid bacillus alone 
was found, were due to a primary mixed infection 
from the pyogenic bacteria and the typhoid bacilli, 
but that the former had perished after producing the 
suppuration, leaving the typhoid bacillus alone in 
the pus. 

But in some cases, as Kamen 6 has pointed out, 
the interval that elapsed was too short (less than 

1 Correspondenzbl. schweiz. Aerzte. Feb. 15, 1 891. 

2 Johns Hopkins Hosp. Reports, vol. v. 

3 La France Med., 1885, ii, 1821. 

4 Bull. Soc. Med. des Hop., 3d series, vol. viii, p. 90. 

5 Jour. Pathol, and Bacterid., 1894, iii, 202. 

6 Internat. klin. Rundschau, 1890, Nos. 3 and 4. 



PATHOLOGY. 37 

two weeks) for us to suppose that the pyogeni< 
bacteria could have died out ; and the result of ex- 
periments upon animals and the now very numerous 
cases in which the typhoid bacillus alone; has been 
found in man preclude the probability of this as- 
sumption. 

The results noted in the various chapters follow- 
ing, show that it is specifically stated that " pure 
cultures" of the typhoid bacilli were found in 63 
out of 82 cases of suppuration of various kinds. 
In making the resumes, undoubtedly the word 
"pure" was sometimes accidentally omitted by us, 
so that the truth is probably under, rather than over, 
stated. The extreme disproportion in the figures 
as they stand, however, is a most convincing proof 
of the unquestionable pyogenic property of the 
typhoid bacillus. 

Experiments upon animals have pointed positively 
also in the same direction. 

Both of these points are more fully considered in 
the next section of this chapter. This, however, is 
a favorable opportunity to consider the results of 
laboratory researches to determine the behavior of 
the pyogenic bacteria in mixed cultures, especially 
the staphylococcus and the streptococcus. 

Vincent, 1 in mixed cultures of the bacillus of 
Eberth and the staphylococcus or the streptococcus, 
has observed the greatest difference in the influence 
of these two pyogenic organisms on the bacillus of 
typhoid. The staphylococcus is remarkably inimical 
to the growth of the bacillus of typhoid, so that the 
latter will disappear from a mixed culture, while, on 

1 Ann. de l'lnstitut Pasteur, 1893, vii, 141. 



38 SURGERY OF TYPHOID FEVER. 

the contrary, when mixed with the streptococcus, 
the typhoid bacillus grows vigorously. In his ex- 
perimental researches he found that doses of the 
streptococcus or of the bacillus of typhoid, neither 
of which was fatal if injected singly, if injected 
together would produce the most violent reaction 
and death. In 41 cases of typhoid in which various 
suppurative processes occurred, in 32 the complica- 
tion was due to the aureus or albus. All of these 
recovered in spite of extensive suppuration and 
multiple periostitis. On the other hand, of eight 
cases in which the streptococcus either alone or 
associated with the bacillus of Eberth was found, 
five died, showing a striking difference in the fatality 
especially of the mixed infection by these two pyo- 
genic organisms. 

Valliard 1 says that if two animals are infected, 
the first with a feeble dose of the streptococcus and 
the second with a similar dose of the typhoid bacil- 
lus, both will be ill for a few days and then recover, 
but that if a third animal is infected with the same 
dose of the two bacilli together death follows with 
stupor, diarrhea, and fever. Dr. Kyle informs 
me that he has observed the same fatality after 
mixed infection with the streptococcus and other 
bacteria. 

Orloff 2 also has shown that six weeks after an 
injection of mixed cultures of the typhoid bacillus 
with the albus and the aureus, the latter was not 
destroyed but that in one-third of the cases the 
albus had disappeared. 

1 Quoted by Grancher, Bull. Med., 1892, vi, 1273. 
* Centralbl. f. Chir., 1890, p. 387. 



PATHOLOGY. 39 

The acknowledged difficulty of distinguishing be 
tween the colon bacillus and that of typhoid is also 
alleged as a reason for doubting the pyogenic faculty 
of the latter and toascribe the suppuration to the colon 
bacillus. But first the number of cases of suppura- 
tion which the typhoid bacillus has been found in pure 
culture (p. 37) is such as to make it very improbable 
that they could all be due to the colon bacillus in 
so distant and so many organs and tissues ; and, 
secondly, the very exact and careful differentiation of 
the two bacilli by their various stains and different 
reactions which, in view of this very objection, have 
been made by Flexner, Dmochowski and Janowski, 
Haushalter, Ouervain, Bruni, Ohlmacher, and others, 
would overthrow the objection. 

The following remarks by Flexner show that 
this differentiation is now not only possible but 
certain : 

" The weight of opinion among bacteriologists at 
this time is that the colon group of organisms can 
be sharply differentiated from the typhoid bacillus. 
However, it no longer suffices for distinguishing 
them to observe the colony growth upon agar-agar, 
gelatin plates, or the growth upon potato ; neither 
does the possession of mobility and stainable flagella 
serve to distinguish the typhoid from the colon bacil- 
lus. On the other hand, the power of acid and 
indol production, the property of setting up fermen- 
tative changes in suear, with the liberation of ^as and 
the coagulating influence upon milk, possessed by 
the colon group of organisms, separate it from the 
typhoid organism, which produces alkali, does not 
yield indol in cultures, is not capable of ferment- 



40 SURGERY OF TYPHOID FEVER. 

ing sugar, and has no coagulating effect upon 
milk." * 

In at least once case of superficial necrosis of the 
femur, Klemm 2 has found both the colon and the 
typhoid bacilli co-existing. While, therefore, it is 
possible that the pyogenic bacteria may have been 
the cause of the suppuration in many of the cases 
and may have died out in others, it is undoubtedly 
true that the typhoid bacilli have very frequently a 
pyogenic faculty. 

Why in some conditions the typhoid bacillus 
should be pyogenic and in others not, we can only 
at present speculate. No reason can be alleged. 
But we are precisely in the same position as to the 
pyogenic function of other bacilli, — for example, the 
colon bacillus, which we certainly know to be a 
possible if not indeed a frequent cause of sup- 
puration in certain conditions, — e.g., appendicitis, — 
whereas ordinarily it is an entirely harmless intes- 
tinal organism. 

IV. The Pyogenic Faculty of the Typhoid 
Bacilli. — The proof of this lies first in observed 
cases in man in which the typhoid bacilli have been 
found in pure culture, and, secondly, in experiments 
upon animals. The first to observe this pyogenic 
property of the typhoid bacilli were Rendu, 3 Fraen- 
kel, 4 and Tavel. 5 

1 Flexner, Jour. Pathology and Bacteriology, 1895-96, vol. .ii, p. 20. 
On the same page, in a foot-note, he mentions the various recent methods of 
distinguishing between the two bacilli. 

2 Arch. f. klin. Chir. , xlviii, 692. 3 La France Med., 1885, ii. 

4 Sechste Kongress Inn. Med., 1887. 

5 Correspondenzbl. schweiz. Aerzte, 1887. 



PATHOLOGY. 41 

(a) In Man. — The objections have been consid- 
ered in the preceding section. 

As already stated, there are at least 63 cases in 
which the typhoid bacillus alone existed in various 
suppurative disorders, and 19 more in which the ty- 
phoid bacillus was found, but no mention is made — 
at least in the table — as to whether other organisms 
were sought and found. It is, however, reasonable 
to conclude that any careful bacteriologist would 
not limit his search to the typhoid bacillus alone, and 
that had other organisms been found, it would have 
been so stated. Nearly all of the 82 cases taken 
together, therefore, were probably cases in which 
the typhoid bacillus existed in pure culture in sup- 
purative lesions. 

That they were also the direct cause of the sup- 
puration both the number of the cases and the other 
confirmatory evidence seem to prove. Certainly the 
burden of proof lies upon the opponents of this 
reasonable view. 

Not only the number of these cases, but their 
wide distribution, is worthy of note. The typhoid 
bacilli have been found in pure culture in sup- 
purative lesions in the ribs, clavicle, radius, ulna, 
femur, tibia, and the bones of the finders and the 
toes; in the blood, heart-muscle, the endocardium, 
and the arteries and the veins of the legs ; in the 
muscles of the neck, shoulder, abdominal wall, and 
legs ; in the peritoneal cavity, the spleen, the liver, 
the bile, the kidney, the urine, and the mesenteric 
glands ; in the brain ; in the parotid gland ; in the 
thyroid gland ; in the lungs and the pleura ; in the 
ovary ; in the testicle. 



42 SURGERY OF TYPHOID FEVER. 

(b) In Animals — There is now a large number of 
experiments in which the injection of the typhoid bacil- 
lus in pure culture, obtained from human subjects, has 
produced suppuration in animals. No other known 
cause existed for the suppuration, and the inference 
that the typhoid bacillus was the cause is unavoidable. 

The present work is scarcely the place in which to 
discuss this subject in detail, but those interested in 
the subject may consult the following authors who 
have furnished such proof of the pyogenic faculty of 
the typhoid bacilli. The somewhat extensive list — 
and it could have been much enlarged — shows that 
this property of the bacillus of Eberth has received 
experimental support from very many careful ob- 
servers : 

Sirotinin, Zeitschr. f. Hyg., i, 1886. 

Beumer and Peiper, Zeitschr. f. Hyg., i, 1886, and 
ii, 1887. 

Colzi, Lo Sperimentale, 1890, lxv, 623. 

Buschke, Fortschritte d. Med., 1894, xii, 613. 

Gaffky, Mitth. kaiserl. Gesundheitsamte, Berlin, 
ii, 1884. 

Fraenkel and Simmonds, Aetiolog. Bedeut. d. Ty- 
phusbacillen, Leipzig, 1886. 

Seitz, Centralbl. f. Bakteriol., ii, 1887. 

Melchoir, Dehu, loc. cit., p. 187. 

Achalme, Soc. Biol., June 11, 1890. 

Orloff, Pein, loc. cit., p. 79. 

Gilbert and Girode, Bull. Soc. Biol., July 11, 1890, 
and May 2, 1891. 

Michon, Des Supp. dans la Fievre Typhoide, 
These de Paris, 1890. 

Gasser, Pein, loc. cit., p. 88. 

Dmochowski and Janowski, Ziegler's Beitrage, 
xvii, 1895. 



PATHOLOGY. 43 

Typhoid Infection of Different Organs 
Without Typical Typhoid Lesions in the In- 
testine. — A number of cases of typhoid infection in 
various parts of the body, — very largely surgical, — 
without any typhoid lesions in the intestine, have 
been reported. Those which I have met with are as 
follows : 

i. In the Spleen. — Du Cazal 1 reports the case of a 
man, age twenty-one, who had pneumonia and pleu- 
risy, enlarged spleen with great tympany, bleeding 
from the nose, and headache, but no typhoid spots. 
He was admitted to the hospital March 2, 1893, anc ^ 
died on the 13th, about the twenty-third day of the 
disease. Typhoid bacilli in pure culture were found 
in the spleen, and their identity was confirmed by 
experiments upon animals. The intestines were 
entirely free from any typhoid lesion. He refers also 
to cases by Vincent, Valliard, Chantemesse, Rendu, 
Fernet, and Kelsch. 

2. In the Spleen, Blood, and Urine. — Cheadle 2 re- 
ports a very carefully examined case of typhoid fever 
without ulceration of the intestine in which both the 
"Widal serum-test during life and the bacterio- 
logical examination made after the death of the 
patient rendered the diagnosis absolutely certain." 
A boy, aged three, was admitted to the hospital No- 
vember 8, 1896, with a history of diarrhea, vomit- 
ing, and debility. A brother and a sister of the 
patient had been in the same hospital suffering 
from typhoid fever. Rose-colored spots appeared, 
the abdomen was swollen and tympanitic, and the 

1 Bull, et Mem. Soc. Med. des Hop., 1S93, P- 2 43- 

2 Lancet, 1897, ii, 254. 



44 SURGERY OF TYPHOID FEVER. 

liver was enlarged but the spleen was not. Ten 
days after his admission, and probably about the 
twentieth day of the disease, epistaxis and vomiting 
occurred. By the twenty-sixth day he was coma- 
tose, and died December ist, about the thirty-third 
day of the disease. 

" On the twenty-first day of the disease, November 
19th, on applying the serum-test Mr. MacCallan 
found that there were loss of motility of most of the 
bacilli and marked clump formation. The typhoid 
bacillus was separated- from the urine on the twenty- 
sixth day of the disease by Parietti's method. On 
the thirty-second day he suspended in five c.c. of 
water part of a two-day-old stock culture of the 
bacillus, and to this were added two drops of blood 
from the patient. The fluid, previously cloudy, be- 
came clear after some hours, the bacilli having 
formed clumps and settled to the bottom of the 
tube as a flocculent, uneven mass. 

"At the post-mortem examination no ulceration of 
the intestine was visible, and Peyer's patches and the 
colon appeared to be normal. * * * * The 
spleen was normal in size and appearance, was 
opened aseptically, and cultures on agar, gela- 
tin, and potato were made. The culture-tubes 
after incubation showed typical colonies of the 
typhoid bacillus. Mr. MacCallan examined micro- 
scopically for typhoid bacilli 30 or 40 sections of the 
spleen, but was unable to recognize any. This was 
not surprising, as Gaffky says that it is sometimes 
necessary to examine 200 stained microscopical sec- 
tions of the spleen in case of typhoid fever before 
groups of the bacilli can be recognized. The mes- 



PATHOLOGY. 45 

enteric glands and liver were enlarged. Before the 
heart was opened, blood was collected from the right 

auricle in Pasteur pipettes, and the scrum-test was 
carried out with a culture of bacilli which had been 
separated from the patient's urine. Loss of motility 
in most of the bacilli and clump formation were 
observed." 

3. In the Spleen. — Hodenpyl, in a paper soon to be 
published in the British Medical Journal, 1 reports the 
case of a man, age thirty-one, who had all the ordin- 
ary symptoms of a " typical typhoid fever, including 
the rash, of a severe type." He died on the seven- 
teenth day of the disease. The necropsy showed 
"no enlargement of the mesenteric lymph-nodes. 
:i: *« :i: :;: The mucous membrane of the small in- 
testine was pale. There was neither swelling nor 
ulceration of the lymphatic structures. Careful ex- 
amination of Peyer's patches by transmitted light 
failed to reveal the slightest lesion. The appendix 
was normal. The colon was dilated and thickly 
studded with ulcers." The bacteriological examina- 
tion was made by Dr. E. H. Wilson, bacteriologist to 
the Brooklyn Board of Health, and later by Drs. Hiss 
and Dyar, assistants in bacteriology in the labora- 
tory of the College of Physicians and Surgeons, who, 
working independently of each other, identified the 
cultures from the spleen as those of the bacillus of 
typhoid. 

4. In the Spleen. — Beatty 2 reports the case of a 
man, age thirty-four, who died on the sixth day of 
illness. Death was preceded by jaundice, hematuria, 

1 Brit. Med. Jour., 1897, ii, or 1898, i. 

2 Brit. Med. Jour., 1897, i, 148. 



46 SURGERY OF TYPHOID FEVER. 

and coma. Post-mortem, the spleen and mesenteric 
glands were enlarged, but the intestines were healthy. 
From the spleen typhoid bacilli were grown. 

He also reports a second case, supposed to be 
similar to this, but in which no bacteriological ex- 
amination was made. 

5. In the Spleen. — Banti 1 reports the case of a 
woman, age thirty-one, who died on the twenty-sixth 
day of a typical and apparently uncomplicated attack 
of typhoid fever. The autopsy showed no lesion 
of the intestine, but the stained section of the spleen 
demonstrated bacteria, which Banti regarded as 
typhoid bacilli. 

6. In the Spleen. — Karlinski 2 reports three cases, 
occurring in a wide-spread epidemic of typhoid fever, 
which presented, during life, the symptoms of this 
disease. They were affected in much the same way 
as other fatal cases, which last showed at autopsy the 
characteristic lesions of the small intestine in typhoid 
fever. The autopsies of these three fatal cases failed 
to show any involvement of the lymphatic structures, 
nor was there swelling or ulceration of either large 
or small intestines. The mesenteric lymph-nodes 
and spleen were swollen in each case. In one case 
the spleen was five times its normal size. Culti- 
vations from the spleen revealed the presence of 
the typhoid bacillus in each case. 

7. In the Brain. — Balp 3 reports a case in which the 
patient entered the hospital, having had a fall which 
caused unconsciousness and fracture of the humerus. 



1 Riforma Med., 1887, 1448. 

2 Wien. med. Wochen., 1891, 470. 

3 Revist. Gen. Ital. Clin. Med., 1890, 406. 



PATHOLOl.Y 47 

Suppurative meningitis, both spinal and cerebral, was 
found at the post-mortem. There was a tear of the 
nasal mucous membrane communicating with the 
meninges. In the pus from the meninges was found 
the bacillus of Eberth. 

8. In the Brain. — Neumann and Schaeffer 1 report 
the case of a woman who died in the hospital uncon- 
scious and without history. No lesions of typhoid 
were found in the intestine, but from the meninges 
were obtained pure cultures of the typhoid bacillus. 

9. In the Brain. — Adenot 2 reports a case in which 
there was absolutely no lesion found in the kidneys, 
spleen, mesenteric glands, or intestines, and yet the 
patient died on the tenth day, five days after the 
onset of meningitis, and in the fluid infiltrating the 
brain — for there was no pus — the bacillus of Eberth 
was found in pure culture. 

10. In Pleuritic Pus. — Charrin 3 reports the case of 
a man who died of a purulent pleurisy. The bacteri- 
ological examination of the fluid showed the presence 
of the typhoid bacillus, but none of the intestinal 
lesions of typhoid were found. 

11. In a Suppurative Goiter. — Kummer and Tavel 4 
report a case in which there was suppuration in an 
old goiter, due to the typhoid bacillus. The thyroid 
disease began on the second day. No typhoid 
bacilli were found in the stools, and no other evi- 
dences of typhoid infection were present. The 
bacteriological examination by Tavel was made, it is 
true, by older methods, but was most careful and 

1 Virchow's Arch., 1887, cix, 477. 

2 Lyon Med., 1889, Nos. 34 and 36. 

3 Soc. Med. des Hop., March 17, 1891. 4 Rev. de Chir., 1891, 507. 



48 SURGERY OF TYPHOID FEVER. 

exhaustive. The patient made an excellent re- 
covery. 

12. In the Gall=bladder. — Osier * records a case of 
acute cholecystitis under the care of Halsted and 
Gushing. A woman, age twenty-six, who had never 
had any illness resembling typhoid fever, on March 
i, 1897, after an enormous meal, was seized with 
vomiting, fever, and pain in the region of the gall- 
bladder, with indistinct tumefaction. On March 
1 6th Halsted operated, finding a large gall-bladder 
distended with a brownish-tinted material and 15 
large stones. She recovered. Cushing made cul- 
tures showing the presence of the typhoid bacillus, 
and the patient's blood gave the characteristic indol 
reaction to this and to another culture of typhoid 
bacilli. 

13. In the Liver, Spleen, and Bloodc — Guarnieri 2 re- 
ports a case of angiocholitis, produced by the 
typhoid bacillus, without the characteristic lesions of 
typhoid in the intestine. The bacillus was culti- 
vated from the liver and spleen, and from the blood 
of the patient twelve days before death. 

The following additional references to cases show- 
ing the presence of typhoid bacilli in various organs, 
but without typhoid lesions in the intestine, have 
been kindly furnished me by Dr. Flexner : 

14. In the Intestine. — Widal 3 gives the following 
references : In a case of Pick's 4 the sero-diagnosis 

1 Trans. Assoc. Arner. Phys., 1897, xii, 396. 

2 Baumgarten's Jahresbericht, 1892, vol. viii, 234, from Revist. Gen. di 
Clin. Med., 1892, p. 234. 

3 Etude sur le Serodiagnostic, etc. Ann. de l'Institut Pasteur, May, 
1897, p. 426. 

4 Wien. klin. Wochen., 1897, No. 4, 82. 



PATHOLOGY. 49 

had been positive during life. At the autopsy. the 

lesions of typhoid fever were not found in the intes- 
tine or in the spleen, but the typhoid bacillus was 
cultivated from the intestine. 

15. In the Spleen, Lungs, and Pleural Effusion. — Iu 

the case of Chambon and Menard, 1 the disease; pre- 
sented during life the symptoms of typhoid fever 
and acute tuberculosis. The sero-diagnosis was 
positive three times. The autopsy showed granules 
(tubercles?) in the lungs, meninges, kidneys, liver, 
spleen, and intestines, but no typhoid lesions in the 
intestines. Cultures from the spleen, lungs, and 
pleural effusion gave a bacillus which was identified 
as the bacillus typhosus. 

Flexner 2 and Hodenpyl accept the case of Du 
Cazal as proved from the bacteriological point of 
view, but reject other cases as not differentiating the 
colon and the typhoid bacilli with sufficient accuracy 
by the methods employed. I do not feel myself 
competent to decide such a technical point, but will 
only call attention to two facts : 

First, the cases of Cheadle and Hodenpyl seem 
to have been most carefully studied by the later 
methods, and that of Kummer and Tavel with 
equal care by older methods, and would seem to be 
fairly conclusive. Moreover, if the single case of 
Du Cazal is accepted, the principle is admitted ; and 
if admitted in one case, — rare, it is true, but accepted 
as certain, — then there is no reason why it may not 
be true in other cases. 

Secondly, while in this or that case the conclusion 

1 Soc. Med. des Hop., 1S97, No. 2. 

2 Jour. Path, and Bacterid., 1895, 210. 



50 SURGERY OF TYPHOID FEVER. 

might be erroneous, it is hard to believe that over a 
dozen observers — careful men, trained to their work 
— would all be wrong. Even if they did work with 
imperfect methods, their conclusions, when supported 
by the three or four acknowledged to have been in- 
vestigated by accurate and modern methods, it 
seems to me, must be accepted as in general correct. 

Possibly the explanation of those cases of infection 
in which the typhoid bacilli have attacked not the in- 
testine but other organs may be found in the investi- 
gations of Remlinger and Schneider. 1 These authors 
found the typhoid bacillus in earth, in drinking water, 
and in the intestinal canal in healthy persons. The 
bacteria obtained resembled those from true typhoid 
stools in form, culture, and biological tests, but they 
were less virulent and the cultures were not affected 
by the serum-test. They believe that Eberth's bacil- 
lus is, to a certain degree, ubiquitous, that it occurs 
in drinking water, in the soil, and in the digestive 
tract of healthy persons as well as in those suffering 
from typhoid ; that it can remain in the bowel of 
healthy persons innocuous until an accidental weak- 
ening of the intestine or the appearance of other 
bacteria gives it the power to manifest its action. 

Pancini, 2 after investigating six cases (abscess of 
the liver from dysentery, suppurating echinococcus 
cysts, etc.), in all of which a bacillus in all respects 
resembling the typhoid bacillus was found, but with- 
out any typhoid fever or typhoid intestinal lesions, 
says that one of three conclusions is inevitable : 
(i) That typhoid bacilli are so frequently found in 

1 Ann. de l'lnstitut Pasteur, vol. xi, p. i. 

2 Riforma Med., 1893, 95, in Centralbl. f. Bakteriol., 1893, xiv, 497. 



PATHOLOCY. 51 

the human intestine as to be regarded as normal ; 
(2) that the colon bacilli can not be distinguished 
from the typhoid bacilli ; or (3) that the typhoid bacilli 
must be only varieties of the colon bacilli. 

Which of these conclusions is correct I do not feel 
myself competent to judge, and most probably it is 
as yet an unsolved problem. 

Frangulea, 1 in a paper at the recent Moscow Con- 
gress, accepts the last very frankly. 

Hiss, in an important recent paper, 2 has pointed 
out the means of differentiating the two with ap- 
proximate certainty. Flexner 3 has done the same. 

1 Verein's Beilage z. Deutsch. med. Wochen., Sept. 16, 1897, 187. 

2 Jour, of Exp. Med., ii, 677. 

3 Jour. Path, and Bacterid., 1895. 



CHAPTER III. 
TYPHOID GANGRENE. 1 

English and American authors in the past have 
not given the attention to gangrene after typhoid 
which its importance deserves. Thus Reynolds and 
Bartholow make no allusion to it ; Wilson only al- 
ludes to gangrene of the lung and the mouth, two 
of its rarer sequels ; Flint mentions it, but had never 
seen a case ; while Murchison in his classical work, 
and Hutchinson in an excellent chapter on typhoid 
in Pepper's System of Medicine give it only a 
brief notice. Nor have the surgeons done it any 
better justice. Neither Gross, Agnew, Ashhurst, nor 
Holmes 2 mention it. Barwell 3 refers to it briefly. 
It is not mentioned in Dennis' or Park's System of 
Surgery and not alluded to in Treves' System. 

We owe our chief knowledge of the subject to 
French authors, and to a few recent German and 
Americans publications. Larrey, 4 Hildebrand, 5 Ali- 
bert, 6 and Fabre 7 mention sporadic cases of gan- 
grene, but attention was first seriously called to its 
occurrence in typhoid fever in 1857 by Bourgeois 8 

1 This chapter is based partly on my Toner Lecture, but is chiefly an ex- 
pansion of the Shattuck Lecture (see preface). Some paragraphs in that 
lecture which were merely incidental are omitted, and others have been 
transferred to the introduction. 

2 System of Surgery. 3 International Encyclopedia of Surgery. 
4 Mem. et Campagnes, iii, 72. 5 Typhus Contagieux, 1806. 

6 These de Paris, 1838. 7 Gaz. Med. de Paris, 185 1, 539. 

v Bull. Soc. Med. des Hop., Paris, 1857, iii, 311. 

52 



TYPHOID GANGRENE. 53 

and Bourguet. 1 The next papers of any importance 
were by Gigon in 1 86 1 and 1863. 2 The former es- 
tablished the fact of gangrene from arte* rial obstruc- 
tion by autopsy, though he regarded the gangrene 
as a coincidence rather than a consequence of the 
fever. In 1863, Patry 3 confirmed these earlier ob- 
servations. The cases reported by these authors 
were included in the summary published in the 
Toner Lecture (1876) already alluded to. 

Since my own contribution, some of the more 
important papers are those of Spillman, 4 Gaston 
David, 5 Barie, 6 Deschamps, 7 Haushalter, 8 Flexner, 9 
and Ouervain, 10 besides a very large number of in- 
dividual cases, which have been reported by various 
authors. 

Under gangrene I exclude from consideration the 
familiar and frequent bedsores, which, though actu- 
ally often partaking of this character, are scarcely 
in the same category as the cases I shall consider. 

One would suppose a priori that gangrene would 
only follow severe attacks, but so large a number 
of cases of gangrene have been reported after rela- 
tively mild attacks, that we must concede the possi- 

1 Gaz. Hebdom., 1857, 646. 2 L'Union Med. 

3 Arch. Gen., 1863, i, 129, 549. 

4 Gangrene des Organes Genitaux de la Femme, Arch. Gen., 1881, 7th 
series, vi, 150. 

5 La Gangrene Typhoide, These de Paris, 1883. 

6 L'Arterite aigue' consec. a la Fievre Typhoide, Rev. de Med., 18S4, iv, 
No. 1. 

7 L'Arterite aigue dans la Cours de la Fievre Typhoide, These de Paris, 
1886. 

s Merc. Med., September 20, 1893, 453- 

9 Johns Hopkins Hosp. Rep., Nov., 1894, 120 ; and Jour. Path, and Bac- 
teriol., Nov., 1894, iii, 202. 

10 Centralbl. f. inner. Med., August 17, 1895, 793. 



54 SURGERY OF TYPHOID FEVER. 

bility of gangrene in mild cases as well as severe 
ones. Hence the watchfulness of the physician 
should never relax by reason of the fact that the 
case is running a mild course, and that gangrene is 
an infrequent result of typhoid. 

While gangrene is an important complication or 
sequel of typhoid, it is fortunately rare, so that most 
practitioners, and even some men of vast experience 
in large hospitals, have never seen a case — for ex- 
ample, Flint and Murchison. Holscher, 1 in. 2000 
fatal cases of typhoid, does not report a single case, 
though he records 59 cases of thrombosis of the 
femoral vein, and Bettke, 2 in 1420 cases, found only 
four cases of gangrene, all limited to the toes. In 
my former lecture I tabulated 43 cases from typhoid 
and 56 from typhus. 3 Since 1876, Dr. Westcott has 
found 90 cases of actual gangrene, of which 72 fol- 
lowed typhoid, in addition to which he has tabulated 
21 cases of arterial and 48 of venous thrombosis not 
followed by gangrene. In its infrequency, therefore, 
it is in marked contrast to the bone lesions, of which 
he has found 168 cases, all after typhoid, to which, 
from my former lecture, are to be added 37 after 
typhoid and four after typhus, or a total in typhoid 
alone of 205 cases of bone lesions to 133 of gan- 
grene. 

Date of Onset. — While gangrene is generally a 
late complication during the course of the fever, or an 
early sequel during convalescence, it is never a very 

1 Munch, med. Wochen., 1891, xxxviii, 43. 2 Inaug.-Diss. , Basel, 1870. 

3 Thirty-four of these after typhus were reported by Estlander (Langen- 
beck's Archiv, 1870, p. 453) in a frightful epidemic following a financial 
crisis and a series of bad harvests in 1862-67, m Finland. 



TYPHOID GANGRENE. 55 

late sequel, as is the case in the bone lesions. The 
latter often do not occur until several weeks, some- 
times months and occasionally even years, after the 
attack of fever. This is doubtless due to the fact 
that the bacilli of typhoid find a favorable nidus in 
the bones, especially in the marrow, and have been re- 
peatedly demonstrated by stain and culture after six, 
twelve, or eighteen months, and even after so extra- 
ordinary long a period as six 1 or seven years. 2 In 
addition to this, the slowness of all pathological pro- 
cesses in the hard osseous tissues, as contrasted 
with their rapidity in the soft parts, would naturally 
lead us to expect that gangrene would occur far 
earlier than lesions in the osseous tissues, yet ab- 
scess of the brain may occur two or three months 
after the fever (see Chapter VIII). 

The earliest time at which gangrene occurred, 
I find, is on the fourteenth day, 3 and the latest in the 
seventh week. 4 By far the commonest time for this 
dangerous complication to appear is the second and 
third weeks, during which 39.2 per cent, of all the 
cases occurred. 

The causes for the appearance of gangrene in the 
second or third weeks, or late rather than early in 
the disease, are probably twofold. First, during the 
earlier stages of the disease the general vitality of 
the patient and the resistance of the tissues are such 
that they can combat successfully the evil tendencies 
of the fever; but, secondly and chiefly, just as for 

1 Sultan, Deutsch. med. Wochen., 1S94, 675. 

2 Buschke, Fortschritte d. Med., 1894, 573. 

3 Donald, Lancet, 1892, i, 417. 

4 Forgues, Rec. de Med. Mil. 



56 SURGERY OF TYPHOID FEVER. 

the production of the intestinal lesions, so for the 
gangrene, a certain length of time is required for 
the diffusion of the bacilli and their toxic products, 
and for their resulting evil effects. Both causes 
unite in working together and to the same end. By 
the second or the third week the bacilli and their 
toxic products have become diffused through the 
system; excessive feebleness has followed the small 
amount of food taken and the exhaustion from the 
continued high temperature; the heart 1 has become 
weakened, which favors the formation of thrombi, not 
only in the heart but also in the vessels, either as a 
result of arteritis or of autochthonous thrombosis ; 
emboli frequently result ; and with the sluggish cir- 
culation, the general enfeeblement both of mind and 
body, and the frequently obstructed vessels, the 
advent of gangrene at this period of the fever should 
occasion no surprise. Indeed, the surprise is rather 
that it is so rare. 

Let us now consider the pathology, symptoma- 
tology, and treatment. 

Pathology. — Various writers have been the par- 
tizans of one or another single cause for the occur- 
rence of gangrene during and after typhoid fever. 
This seems to me an error, for, as I hope to show, 
there are a number of causes, of which one will exist 
in one case and another in another case, sometimes 
singly, sometimes in combination. 

1 We do not appreciate how much a continued high temperature alone 
exhausts a patient. Were the body composed of water alone, to raise the 
temperature of a person weighing 150 pounds from 98. 5 to 103. 5 , — i. e. five 
degrees (to say nothing of the expenditure of force needful to keep it there), — 
requires an expenditure of force equal to raising 285 tons one foot (i5°X5 
X772 foot pounds). A girl of 100 pounds weight, simply lying still in bed, 
suffering from such a fever, does daily the work of two or three men. 



TYPHOID GANGRENE. 57 

In my Toner Lecture I was disposed to regard 
the causes of gangrene as chiefly three : first, the 
altered blood ; secondly, the weakened heart ; and, 
thirdly, the mechanical difficulties in carrying- on the 
circulation, especially in distant parts ; and that all 
of these caused the gangrene by the production of 
thrombi, either macroscopic or microscopic. Since 
that lecture was delivered, however, the bacillus of 
typhoid has been discovered, and has been proved 
by a number of careful examinations to play an im- 
portant, and in some cases at least a direct, role in 
the production of gangrene. It is greatly to be re- 
gretted that only very few cases have been studied 
with the scientific precision which they deserve. By 
calling renewed attention to the subject, however, I 
hope to stimulate others, especially in this country, 
to make thorough bacteriological examinations in 
the future. Every chapter in this monograph shows 
how deficient our knowledge is for want of such in- 
vestigations. All the more are such careful exam- 
inations necessary, since the opportunities to make 
them are so rare, and when they do occur it is only 
too seldom that it is in the hands of men with 
the opportunity, the capability, and the disposition 
for making such examinations. 

In two cases in my tables ergot had been freely 
given in consequence of hemorrhage. 1 Were these 
the only cases of gangrene, one might suppose that 
this had had a determining influence, but as gan- 
grene followed in &8 other cases, in none of which 

1 Finlayson, Amer. Jour. Med. Sci., March, 1891, and Sarda, Rev. Gen. 
de Clin, et de Therap., 1892, vi, 401. 



58 SURGERY OF TYPHOID FEVER. 

had this drug- been administered, its exhibition must 
be considered as merely incidental. 

As a foundation for our study of the pathology of 
typhoid gangrene, let me recall a few of the facts 
which have been demonstrated bacteriologically. 

First, not a few cases of typhoid fever suffer from 
a mixed infection. This is much more apt to lead, 
however, to other disorders than gangrene. For 
example, as I shall show hereafter, there have been a 
number of cases of tetanus, erysipelas, anthrax, and 
malignant edema, due, of course, to a mixed infection 
of the typhoid and these specific bacteria (Chapter 
XIX). In addition to this, the large number of 
cases of suppurative disorders in various organs, 
bones, spleen, muscles, etc., presume the presence 
of the ordinary pyogenic bacteria, and their presence 
has been proved by stain and culture. In two cases 
in my tables pyemia or septicemia, a rare condition, 
is noted, 1 in both of which the pyemia followed a 
phlebitis without gangrene. 

Turn in £ now to the cases in which bacteriological 
examinations have shown pure cultures of the bacil- 
lus of Eberth, we must note, as bearing upon the 
occurrence of gangrene, that they may be found: 
(a) In the blood ; (b) in the endocardium ; (c) in the 
walls of the arteries; (d) in the walls of the veins; 
(e) in the thrombi ; and (f) in the perivascular 
tissues. 

(a) Typhoid Bacilli in the Blood. — This has already 
been fully considered in Chapter II, page 23, and 
need not be repeated. 

1 Wagner, Brit. Med. Jour., 1891, i, 18; and Spillman, Merc. Med., 1895, 
No. 13, 145. 



TYPHOID GANG RUNE. 59 

(b) In the Endocardium.' — Viti 2 not only found the 
bacillus of Eberth in the granulations of endocar- 
ditis, but by the injections of the bacillus alone into 
rabbits he was able to produce endocarditis with 
vegetations. 

Vincent 3 records another case occurring in a 
soldier who was undoubtedly free from a preceding- 
endocarditis, but died from typhoid, and in the 
vegetations on the mitral valve pure cultures of the 
bacillus of Eberth were found. Girode 4 made a 
similar observation. Gilbert and Lion 5 were also 
able to produce such endocardial vegetations experi- 
mentally by injections of pure culture of the typhoid 
germs. 

Besides the actual discovery of the bacillus of 
Eberth in the endocardial vegetations, it is not un- 
common to find ante-mortem clots in the cavities of 
the heart. Fondues, 6 Beaumanoir, 7 Fritz, 8 and Val- 
lette (quoted by Ferrand 9 ) have all recorded such 
post-mortem findings. These clots are formed prob- 
ably during the period of cardiac weakness, especially 
in the second and third weeks, 10 and, as the heart 
begins to regain its force and lose its frequency, are 
washed into the circulation as emboli. In the viscera 
their presence is shown by multiple infarcts ; in the 
lea-s, bv the occurrence of cranorene. 

1 Cf. Flexner, Jour. Path, and Bacterid. , 1S94, iii, 202, for several cases. 

2 Atti della R. Accademia del Fisiocrkici di Siena, 4th series, vol. ii, fasc. 
5, 6, 1890. 3 Merc. Med., Feb. 17, 1892,73. 

4 Comptes Rendus Soc. Biol., 1889, 622. 5 Comptes Rendus, 1889. 

6 Rec. de Mem. de Med. Mil., 1880, 3d series, xxxvi, 386. 

7 Prog. Med., 1891, ix, 364. 8 Cbarite Annalen, vi, 169. 
9 Contrib. a 1' Etude de la gangrene des membres pendant la cours de la 

Fievre Typhoide, These de Paris, 1S90. 
10 Drewitt, Lancet. 1890, ii, 1023. 



60 SURGERY OF TYPHOID FEVER. 

(c) In the Walls of the Arteries. — Rattone z reports 
four cases in which, in sections of the arterial tunics, 
he was able to obtain pure cultures of the bacillus 
of typhoid. 

(d) In the Walls of the Veins. — Haushalter 2 found 
the bacillus in sections through the veins ; and both 
he and Vaques found the pyogenic microbes in the 
walls of the veins in cases of typhoid phlegmasia. 

Arteritis, endarteritis and peri-arteritis, phlebitis 
and periphlebitis, have been described by a number 
of authors, especially Ferrand, Deschamps, 3 Met- 
tler, 4 Barie, 5 Quervain, 6 and Haushalter. 7 With the 
exception of the last two, the descriptions are pa- 
thological, but without bacteriological confirmation. 
Ferrand 8 quotes numerous cases of endarteritis of 
the iliac, femoral, and popliteal arteries, followed 
by thrombosis and gangrene. Barie describes two 
forms of arteritis ; first, an obliterating form, and, 
secondly, a parietal form. In the first there is pro- 
found alteration of the middle coat, the muscular 
fiber cells being infiltrated with embryonic cells, with 
sclerosis of the external coat and vegetations in the 
lumen. Sometimes, indeed, the three coats are in- 
distinguishable. In others the lining membrane is 
covered with small elevations consisting of masses 
of round and fusiform cells. There is a loss of 
elasticity in the vascular walls, which become fri- 
able and easily distended. The loss of smoothness 

1 Delia Arterite Tifosa in Dehu, loc. cit. 

2 Merc. Med., Sept. 20, 1893, 453. 3 These de Paris, 1886. 
4 Phila. Med. Times, Feb. 19, 1887, 339, and N. Y. Med. Jour., March 

9, 1895, 28 9- 5 Rev - de Med., 1884, iv, 7. 

6 Centralbl. f. inner. Med., Aug. 17, 1895, 793. 

7 Merc. Med., Sept. 20, 1893, 453. 8 These de Paris, 1890. 



TYPHOID GANGRENE. 61 

of the intima, the irregularities of its surface, and the 
diminished caliber from the swelling arc readily con- 
ceived causes for the formation of thrombi, resulting 
frequently in gangrene. The thrombi, at first red, 
but later decolorized, become adherent to the wall, 
and finally the artery becomes a solid cord. Distal 
secondary thrombosis is slow. The lumen of the 
vessel and of its branches is gradually obliterated, 
and the gangrene, therefore, is correspondingly slow, 
and not sudden as in embolism ; but from the ori<>- 

o 

inal thrombi secondary emboli may form, and so 
hasten the gangrene by sudden obliteration of the 
anastomotic circulation. 

As a rule, therefore, in arterial thrombosis the gan- 
grene is dry, but occasionally during the course of 
the dry gangrene from arterial obstruction, the vein 
also becomes obstructed, and part or all of the limb 
may fall into sudden ruin from moist gangrene. 

The parietal arteritis, according to Barie, is not 
attended with thrombosis, and is usually followed by 
recovery. 

That arteritis should occur in typhoid is rendered 
also probable by its appearance in other allied spe- 
cific diseases, such as small-pox, diphtheria, tubercu- 
losis, syphilis, rheumatism, etc. 

How the bacilli reach the walls of an artery or 
vein is a question. Ordinarily they are not found 
in the blood ; and yet the fact that they may be 
widely distributed throughout the body, and that the 
only reasonable mode of such an extensive diffusion 
is by the blood, the cases of Flexner, Vincent, and 
others amply prove (cf. Chapter II). Haushalter 
believes that during their maximum they may reach 



62 SURGERY OF TYPHOID FEVER. 

the vessels by the vasa vasorum, 1 which, it must be 
remembered, especially in the veins, reach the middle, 
and often the internal coat. He is inclined, however, 
to believe that the process is as follows : that an 
infection of the pelvic or crural ganglia occurs, fol- 
lowed by an infection of the perivenous cellular 
tissue by retrograde lymphatic circulation. In these 
cases he supposes that a periphlebitis exists, fol- 
lowed by a secondary endophlebitis precipitating a 
thrombus by the ferment furnished by the bacilli. 
This, I confess, seems to me much less likely than 
the former view. 

(e) In the Thrombi. — Both Rattone and Haushalter 
found the bacillus of typhoid in thrombi. The latter 
calls attention to the fact that he was not able to 
stain them in the thrombus, due, he thinks, to the 
fibrin, which, being decolorized with great difficulty, 
probably obscured the bacilli ; but he was able to 
demonstrate their presence by cultures. He found 
the endothelium of the veins destroyed. On the 
surface of the clot next the vein wall a layer of leu- 
cocytes was intimately united both to the clot and to 
the wall of the vein. The typhoid bacillus existed 
only in the thrombosed portion of the vessels ; and 
he is of the opinion that either the bacilli or their 
products caused the destruction of the endothelium 
and the resulting clot, and that, in all probability, in 
the products of the bacilli was found the ferment 
necessary to produce the coagulation. 

Plate I, from Fraenkel and Simmonds, 2 shows 

1 For a number of cases in which bacteria were found in the vasa vasorum, 
see Lockwood, Traumatic Infection, London, 1896. 

2 Die cetiologische Bedeutung des Typhusbacillen, Leipzig, 1886. 



PLATH I. 






Fig. I. — Section of liver of a patient dead of typhoid fever. Bacilli were found also in 
the spleen, a, A vessel and its branches completely obstructed by typhoid bacilli; below it 
and to the left a close small-cell infiltration which almost entirely obscures the vessel, b, A so- 
called lymphoma. 

Fig. 2. — Enlargement ot Fig. I, a, showing the individual bacilli. 

Fig. 3. — The liver of a rabbit dead after an injection of pure culture of typhoid bacilli in 
the ear-veins. Bacilli were found also in the spleen and the mesenteric glands, a, A vessel 
entirely obstructed by typhoid bacilli. The section shows at various points diffused small-cell 
infiltration. 

Fig. 4. — Enlargement of Fig. 3, a, showing the individual bacilli. (Fraenkel and Sim- 
monds, "Die etiologische Bedeutung des Typhusbacillen," Leipzig, L. Voss, 1886. Repro- 
duced by the kind permission of the authors and publisher.) 



TYPHOID GANGRENE. 63 

excellently the actually observed thrombosis of the 
vessels of the liver by the bacilli of typhoid. 

(/") In the Perivascular Tissue. — Ouervain found 
the bacillus in pure culture in the pus surrounding 
the popliteal artery and vein. That the bacillus 
should cause suppuration around a vessel and be 
found in pure culture ought not now to astonish us. 

The pyogenic power of the typhoid bacillus is fully 
considered in the introduction. 

Having now determined the bacteriological facts, 
let us see how they may be applied pathologically in 
explaining the causation of gangrene. 

The cause of gangrene may be stated in practi- 
cally a single phrase — obstruction to the circulation' 
The three factors I have already quoted from my 
first lecture — the altered blood, the weakened heart, 
and the mechanical difficulties of the circulation in 
distant parts, especially the last two — still hold good, 
but there must be added to them the important role 
of the typhoid bacillus in assisting, and often, it may 
be, in directly precipitating, the coagulation of the 
blood, which is the cause of the obstruction. Four 
different varieties of obstruction, therefore, may 
exist and sometimes co-exist : First, arterial emboli 
of cardiac origin ; secondly, autochthonous thrombi 
in the arteries; thirdly, autochthonous thrombi in the 
veins ; and, fourthly, — probably, though I believe 
there have been no cases absolutely demonstrated 
pathologically, — thrombi in the small peripheral ves- 
sels. In Chapter VIII, on the cerebral complica- 
tions of typhoid, I have reproduced the illustrations 
of Ohlmacher showing- obliterative endarteritis in 

1 Cf. Oliver, Lancet, 1896, i, 1778. 



64 SURGERY OF TYPHOID FEVER. 

suppurative typhoid meningitis. These observations, 
together with the demonstration of actual thrombi 
caused by the typhoid bacilli themselves in the vessels 
as shown by Fraenkel and Simmonds (Plate I), 
throw an important light, it may be, on this cause of 
gangrene. 

I. Arterial Embolism of Cardiac Origin. — This has 
been observed not only at postmortems, but clini- 
cally. Thus, Hayem 1 observed the alteration of the 
heart two days before gangrene of both legs com- 
menced, the first symptoms being acute pain in the 
legs with a sensation of cold. The pulsation disap- 
peared first in the dorsalis pedis, then in the pop- 
liteal, then in the femoral. Amputation showed that, 
though the arterial walls appeared to be healthy, 
the femoral artery was partly obstructed by a clot. 
The obstruction being only partial allowed a feeble 
circulation to go on. The popliteal and all its 
branches below the inferior articular were entirely 
free from any clot. The patient died, and the 
necropsy showed endocarditis and clots in the heart ; 
the aorta was obstructed by a clot extending from its 
bifurcation to a point above the origin of the inferior 
mesenteric, but the iliac arteries were entirely free. 
The spleen and the kidneys presented multiple in- 
farcts. Mercier 2 reports also a case of dry gangrene 
of both legs with fibrinous clots in both the primitive 
iliacs, the deep femoral and the popliteal, the walls of 
which were healthy, and in the left auricle there were 
old fibrinous clots with endocarditis. This form of 
arterial obstruction is quite common in my table, as 
will be observed in the resume on page 74. It leads, 

1 Prog. Med., 1875. 2 Arch. Gen., 7th series, 1878, vol. ii, 402. 



TYPHOID GANGRENE. 65 

as would naturally be supposed, almost always to dry 
gangrene, because it eventually cuts off the supply 
of blood ; as a rule, absolutely ; though in a few cases, 
as in the one quoted from Hayem, a small amount 
of blood may still reach the distal parts and so re- 
strict the extent of the gangrene. The very facts, 
also, that the walls of the arteries were healthy and 
that there were multiple infarcts in the viscera, tes- 
tify to the cardiac origin of such emboli. 

In addition to this I have called attention on pages 
76-yS to the remarkable difference between arterial 
and venous obstruction in relation to their distribu- 
tion to the right or left sides of the body. The al- 
most even balance in arterial obstruction and the 
great inequality in venous obstruction may point 
also to the heart as a factor in arterial obstruction. 

2. Arterial Thrombosis. — In a oreat number of cases 
in the table there were no evidences of preceding 
cardiac disease, and yet obstructive clots were found 
in the arteries, and were followed by dry gangrene. 
These are undoubtedly autochthonous thrombi, 
probably produced largely from the ferment fur- 
nished by the bacilli themselves, or possibly more 
frequently from an endarteritis, such as has been 
already described. 

The consequences of the thrombosis, as of the 
embolism of the arteries, will be a greater or less 
degree of dry gangrene, the extent of which will 
depend upon the completeness or incompleteness of 
the obstruction. 

Sudden thrombosis may be precipitated by very 
slight causes — e.g., Morax z records the case of a man 

1 Bull. Soc. Med. Suisse, 1867, quoted by Mercier. 

5 



66 SURGERY OF TYPHOID FEVER. 

of thirty-five who, when convalescent, after a walk 
felt sudden severe pain in his left leg, followed by 
gangrene from arterial thrombosis. Sometimes, even 
after a careful post-mortem, it may be impossible to 
determine the origin of the obstruction. 

Thus, Valette (quoted by Ferrand) relates a case 
of occlusion of the iliac arteries, gangrene of the 
right leg, vulva, and perineum, with bedsores on the 
thigh and sacral regions setting in on the forty- 
second day. The leg was amputated after eight 
weeks, and the patient, age eighteen, died twenty- 
three days later. The necropsy showed red hepatiza- 
tion of the right lung. There was neither myocardi- 
tis, endocarditis, nor arteritis, but in the left ventricle 
was a clot as large as a small Ggg, yellow, hard, and 
elastic, and extending to the semilunar and the 
mitral valves ; and at the iliac bifurcation on the 
right side, a whitish-gray clot obliterated the external 
and internal iliacs. 

In the Toner Lecture (see Appendix, Fig. i), I 
have copied a figure from Meusel, in which gan- 
grene (necrosis) of a large portion of the skull re- 
sulted from a clot in the middle meningeal. As the 
patient recovered and no mention is made of any 
cardiac trouble, the clot was probably an autochtho- 
nous thrombus. 

3. Venous Thrombosis. — This is much more fre- 
quent than the arterial form, probably from the 
more sluggish circulation, in addition to the infec- 
tious processes which undoubtedly sometimes cause 
a phlebitis or a periphlebitis. 

The phlebitis very frequently results in phleg- 
masia alba dolens. Usually this passes away in a 



TYPHOID GANGRENE. 67 

relatively short time, but it maybe the cause of very 
persistent trouble and annoyance, as in the follow- 
ing instance : 

Case I. — E. C, Milford, Del., age forty-two, first 

consulted me July 9, 1 S 9 7 , at the instance of Dr. 
Marshall. He is an exceedingly large, stout man, 
who, six years ago, had an attack of typhoid fever. 
During his convalescence phlegmasia developed in 
the left leg, from which he has suffered ever since. 
The leg is still swollen, especially from the knee 
down, is very hard, tense, and brawny, is covered 
with crusts of exudation, and is subject constantly to 
small furuncles and the formation of small ulcers 
and occasionally of distinct abscesses. One of these, 
above the internal malleolus, was opened about six 
months a^o and has never healed. At this site 
there is a small crater, one cm. in diameter, (miner 
through the entire thickness of the skin to the 
muscular tissues, and die seat of an exceedingly foul 
discharge. The itching of the limb also annoys 
him very much. I directed him to foment the leg 
sufficiently to take all the crusts off, and then to 
apply an ointment of resorcin, 30 grs. to the ounce. 
Under this treatment he rapidly improved, and was 
soon entirely well. 

Venous thrombosis results in oano-rene in a mod- 
erate number of cases ; but in the majority, as in 
venous thrombosis from puerperal fever, pneumonia, 
etc., gangrene is much less apt to follow venous 
than arterial thrombosis. The circulation is not 
nearly so completely cut off by venous obstruction 
as by arterial, since the collateral venous channels 
are less frequently blocked. Moreover, in arterial 
obstruction the limb below the obstruction is en- 
tirely deprived of blood, whereas in venous obstruc- 



68 SURGERY OF TYPHOID FEVER. 

tion the blood is dammed up in the part beyond the 
obstruction. The circulation may be hindered, but 
if it be not practically entirely arrested, a feeble 
nourishment goes on, sufficient at least to prevent 
gangrene. 

It is to be observed that both in venous and 
arterial thrombosis, especially the latter, the clots 
are often discontinuous. (See cases of Hayem, 
Mercier, and Beaumanoir.) This, possibly, may be 
due to isolated spots of local infection from the 
bacilli. 

The venous clots are often very extensive, much 
more so than the arterial, as shown by a number of 
cases in my table. Thus, in a case of de Santi, 1 the 
clot extended downward to the deep femoral vein 
and upward through the common iliac to the vena 
cava. Beaumanoir 2 reports a case in which there 
were not only clots in the arteries of both legs, but 
also fibrinous clots in the right ventricle and pul- 
monary artery and its branches, in the left auricle, 
and in the femoral arteries and veins and in the 
aorta to the level of the first intercostal artery. 
Naturally such extensive obstruction was followed 
by gangrene of both lower extremities. Clots ex- 
tending into the vena cava are also reported by 
Dumontpallier, 3 Sorel, 4 and Bouley. 5 These were all 
fatal, but Mackintosh, 6 reports one followed by re- 
covery. The attack of typhoid was followed by 
scarlatina, but the swelling of the legs was noticed 

1 Rec. Mem. de Med. Militaires, 3d series, vol. xxxv, 1879, 5° 2 - 

2 Prog. Med., 1891, ix, 364. 

3 Comptes Rendus Soc. Biol., 1879, 6th series, vol. iv, parts 2 and 3. 

4 L' Union Med., 1882, 3d series, vol. xxxiv, 521. 

6 Prog. Med., 1880, viii, 998. 6 Glasgow Med. Jour., 1892, xxviii, 54. 



TYPHOID GANGRENE. 69 

before the latter. The collateral circulation was 
re-established by dilatation of the internal mam- 
mary, superficial epigastric, external pudic, internal 

saphenous, and circumflex iliac veins on both sides. 
The diagnosis seems, therefore, fairly well estab- 
lished. 

Occasionally, as would be supposed, venous throm- 
bosis is followed by sudden death, as in a case 
reported by Nauwerck, 1 of thrombosis of the left 
iliac vein, which was followed by sudden embolism of 
the pulmonary artery while the patient was at stool, 
and death occurred in ten minutes ; and in another re- 
ported by Bouley, 2 also of thrombosis of the external 
iliac vein, which extended to the inferior vena cava 
and the right auricle of the heart, and the patient 
died from syncope. As would naturally be supposed 
also, the thrombosis, both arterial and venous, but 
especially the former, is apt to lead not only fre- 
quently to double gangrene, — for example, of both 
lower extremities, — but sometimes to a gangrene 
which is so symmetrical as to remind one of cases 
of Raynaud's disease. Richard 3 has reported two 
such cases in brothers. A curious coincidence is 
seen in the case of two sisters reported by Trelat, 4 
both of whom had double cataract after typhoid. 
They were both young (one twenty-five). At least 
one was successfully operated on. Had the bacillus 
of Eberth then been known, it would be interesting 
to know whether the cataract was due to a local 
invasion. 

1 Correspondenzbl. schweiz. Aerzte, 1879,485. 

2 Prog. Med., 1880, viii. 998. 

3 L' Union Med., 1880, 3d series, xxix, 1025. 

4 Gaz. des Hop., 1S79, '»> 4 J 7- 



70 SURGERY OF TYPHOID FEVER. 

When the gangrene results from venous obstruction 
rather than arterial, as a rule it is moist. 

Not uncommonly thrombosis of the arteries and 
veins is either successive or simultaneous. In either 
case, the gangrene is apt to be a combination of dry 
and moist gangrene. Occasionally, when the venous 
thrombosis follows the arterial, the gangrene will be 
at first of the dry variety in the distal parts and 
when the venous obstruction occurs moist gangrene 
will follow in the proximal. 

4. Thrombosis in the Peripheral Vessels. — In addi- 
tion to the three forms above recited, there are a 
number of cases reported in which the disease 
began as dry gangrene in the toes and gradually 
crept up the leg. The persistence of pulsation in 
the dorsalis pedis and other higher arteries showed 
that there was no arterial thrombosis or embolism in 
the arteries higher up, but after a time the coagula- 
tion, which presumably had begun at the periphery, 
extended centrally, and first the dorsalis pedis, then 
the tibials at the ankle, and later the popliteal and 
even the femoral were successively obstructed, re- 
sulting, of course, in a more wide-spread gangrene. 
The symptoms show that none of the three preced- 
ing conditions existed, but they enable us by analogy 
to reach the conclusion that spontaneous thrombi 
formed in the distal vessels. Whether the cause of 
this thrombosis is a bacillary infection or not has not 
been studied with that care which it deserves, and no 
absolute pathological or bacteriological confirmation 
of this view, I believe, has been reported. 

Symptoms of Gangrene. — The symptoms of 
gangrene are marked and characteristic. Let us 



TYPHOID GANGRENE. 71 

suppose the case to be one of arterial embolism or 
thrombosis. Toward the end of the fever, especially 
in the third week or early in convalescence?, as weak- 
ness is giving place to strength and the brightest 
hopes of speedy recovery are cherished, sudden, 
severe, and persistent pain is felt. This may be at 
the seat of the impending gangrene, though perhaps 
more commonly it is in the obstructed artery, especi- 
ally in the femoral, popliteal, or tibial, and radiates 
thence toward the periphery. It is followed by numb- 
ness, coldness, loss of sensation, and sometimes of 
motion, and in a short time discoloration and all the 
other usual evidences of gangrene appear. Some- 
times, but not usually, these local symptoms precede 
the pain. If the vessels of the foot or at the ankle, 
or even the popliteal, be examined, the pulsation 
will be found feeble or utterly extinguished, while 
higher up, at the seat of the obstruction, the artery 
will be changed into a moderately firm but very 
tender cord, in which we may sometimes differentiate 
the obstructed artery from the non-obstructed vein — 
an important point in prognosis. Week by week, 
sometimes day by day, the growth of the secondary 
coagulum may be traced upward by the progressive 
abolition of the arterial pulsation and by the upward 
march of the eanerene. If old cicatrices from burns 
or unhealed eczematous ulcers, old fractures, or vari- 
cose veins exist, all loci minor is resistenticz, they will 
be among the earliest parts to yield. Blebs may- 
form in the earlier stages, but generally they will 
dry up and the parts will mummify, although, as 
already indicated, moist gangrene may supervene if 
a large clot form much higher up, or if, in addition 



72 SURGERY OF TYPHOID FEl^ER. 

to the artery, the vein also becomes extensively 
obliterated, thus involving 1 great masses of moist 
tissue, such as the thigh, in sudden ruin. 

As is generally seen in cases of dry gangrene, 
days or weeks will elapse, if the patient live so long, 
during which nature, as usual, makes a powerful 
effort to rid herself of the dead parts by the estab- 
lishment of a line of demarcation. On the establish- 
ment of this, the pain often ceases. 

In case the primary obstruction is in the vein and 
it becomes obliterated extensively and completely 
by a thrombus, or a simultaneous venous and arte- 
rial thrombosis occurs, then the gangrene will be of 
the moist instead of the dry variety. It will present 
the usual appearance of moist gangrene. The ves- 
sels at the seat of the obstruction will be very tender 
and can be felt as hard cords. The clot will extend 
sometimes rapidly and widely, and the gangrene will 
be more extensive in the area involved and far more 
acute in its disastrous clinical course, as would natur- 
ally be expected. 

In the variety of gangrene beginning in the peri- 
pheral vessels, the symptoms will vary somewhat. 
It is not so uniformly in the lower extremity, and 
is much more frequently symmetrical. If small in 
extent, pain is not apt to be a leading feature. The 
onset is often earlier, and from the nature of the 
case its progress is more acute and its limits more 
quickly defined; so that usually, within a few days at 
least, the boundary of the gangrene is well defined. 
Its area also is usually much less than in those cases 
in which a perceptible coagulum exists, not often 
extending in the leg beyond the foot or ankle ; and 



TYPHOID GANGRENE. 73 

if it occur in the nose, cars, genitals, etc., it rarely 
involves surrounding parts to a large extent. Some- 
times, however, it may extend more- widely, as in a 
case of typhus and starvation, mentioned by Lyons, 1 
in which the patient walked to the workhouse, and 
on baring- his chest the whole of the right side was 
11 a dark, olive-green, jelly-like, tremulous mass." 
The abdominal wall is sometimes similarly involved. 
The probably irregular area in which the stasis of 
the blood will take place in this form also accounts 
for the great irregularity generally seen in the line 
of demarcation ; whereas, if a well-defined thrombus 
exists in a large vessel, the gangrene is apt to be 
fairly evenly bounded. This sudden history is usu- 
ally followed by a speedily decided issue. Death 
follows quickly, or reaction and recovery set in 
within a short time, instead of lone hanging in the 
balance. 

In my Toner Lecture I collected in all 113 cases of 
gangrene, to which Dr. Westcott has added 90, mak- 
ing 203 in all. Excluding from the former collection 
34 cases following typhus reported by Estlander in 
Finland, as they were the result of special and 
local causes (see Toner Lecture), of the remaining 
169 cases 115 followed typhoid fever and 40 typhus 
fever. Some of the latter were undoubtedly really 
typhoid. In the following resume I shall combine 
the results of the former and the latter series 
too-ether. 

The influence of age is not very marked. Of 140 
cases, there were under fifteen, 26 cases ; from fifteen 
to twenty-five, 64 cases ; after twenty-five, 50 cases. 

1 On Fever, 19 1. 



74 SURGERY OF TYPHOID FEVER. 

This will not differ much from the normal ao-e-distri- 
bution of typhoid. 

But sex seems to have a marked determining 
influence. Of 155 cases, there were, males, 90; 
females, 65, — or about three males to two females. 

The site of the gangrene is more striking than 
either age or sex. It attacked the 

Ears in 6 cases. Anus in .... . 5 cases. 

Nose in 10 " Genitals in . . . 20 " 

Face, neck, and trunk Legs in 126 " 

in 47 " 

That is, of 214 cases in which the location is 
stated, in 151 it was in the lower extremities, geni- 
tals, and anus, and in 16 more in such peripheral 
districts of the vascular system as the ears and the 
nose. 

I have found in the two series 128 cases of venous 
coagula following typhus and typhoid, especially the 
latter, in which the site is stated. Only four cases 
involved the upper extremity alone, two of which 
were followed by gangrene. Two involved both arm 
and leg, but all the other 124 cases were limited to 
the lower extremities. Gangrene of both venous 
and arterial origin (including both thrombosis and 
embolism) form most frequently during or just after 
the period of greatest cardiac weakness, a weakness 
felt most at such distant points as the legs. Of 41 
arterial cases, 18 ; and of 107 venous cases, 40, 
occurred in the second and third weeks of the fever 
— that is to say, of 148 cases 58 (39.2 per cent.) 
occurred in the second and third weeks. 

These figures, it seems to me, are most instruc- 



TYPHOID GANGRENE. 75 

tive. In discussing the pathology, I gave marked 
prominence to the sluggish peripheral circulation as a 
mechanical factor in the production of the gangrene. 
Even though we admit in many cases the determin- 
ing influence of the bacilli of typhoid, the striking 
clinical fact above established must be explained by 
any accepted pathology. Moreover, this fact is still 
further emphasized when we consider the cases involv- 
ing the joints (Chapter IV), of which 70 were in the 
lower extremities as against 17 in the upper; and 
those involving the bones (Chapter V), of which 112 
were in the lower extremities as against 41 in the 
upper. 

If arteritis or phlebitis or emboli of cardiac origin, 
whether bacillary or not, were the sole or even the 
preponderating cause, then gangrene certainly 
should attack the upper extremities, the head, the 
neck, and trunk with far greater frequency than is in- 
dicated by these statistics. Just as in gangrene from 
other causes, often of non-bacterial origin, such as 
ordinary senile and diabetic gangrene ; or of prob- 
able bacterial origin, as in scarlet fever, measles, and 
the other exanthemata, the legs suffer so much more 
than all the other parts of the body put together, 
so in typhoid gangrene the familiar rule holds good. 
It is also in the lower extremities that venous 
thrombi causing phlegmasia alba clolens are most 
frequent in other diseases of microbic origin, as in 
puerperal fever, pneumonia, septicemia, pyemia, and 
even in tuberculosis and malarial fever. 

In both these classes of diseases arising from half 
a dozen or more different bacteria and in those 
entirely apart from any bacterial influence, the one 



76 SURGERY OF TYPHOID FEVER. 

striking fact is that the legs suffer far more frequently 
than all other parts of the body put together. It is, it 
seems to me then, good common sense and good 
pathological sense to seek for the efficient, the ex- 
citing, the actual cause determinine the location of 
the obstruction and the frequent gangrene in the 
legs themselves as legs ; that is, as distal parts of 
the circulatory system. 

The distribution as to left- and right-sided gan- 
grene is very striking. In the early series I did 
not make such a differentiation, but in the present 
series of 90 cases I have found that of 46 cases of 
arterial gangrene, there occurred on 



& £>' 



Both sides, 8 cases. 

Right side, 19 " 

Left side, 19 " 

showing an exactly even balance of the two sides. 

In the veins, however, the facts are strikingly 
different. Here the obstruction involved 

Both sides, 4 cases. 

Right side, 10 " 

Left side, 38 " 

Total, 52 cases. 

This, as we know, is in accordance with the usual 
experience in other diseases. Why the left side 
should be so much more subject to gangrene due 
to venous obstruction, as also to phlegmasia alba 
dolens, than the right side, has been a subject of 
speculation for many years. My own conviction is 
that the obstruction to the return of the venous blood, 
by reason of the compression of the left common iliac 



TYPHOID GANGRENE. 77 

vein where it passes under the right common iliac 
artery, is the most potent factor ; slight in itself, it 
is true, but when the blood is in unstable equilib- 
rium between fluidity and coagulation, this slight 
retardation is in most cases just sufficient to pre- 
cipitate the coagulation upon the left rather than 
upon the right side. 

The same predominance of the left over the right 
side holds good in cases of venous obstruction, and 
the same balance of the two sides in cases of ar- 
terial obstruction, when they are not followed by 
oauorene. Excluding three involving the Svlvian 
artery, 1 all of which occurred upon the left side, pro- 
ducing right hemiplegia, 2 and one of the right 
brachial artery, 3 and two of the pulmonary artery, 4 
the 15 cases of arterial thrombosis without gangrene 
involved both sides in four cases ; right side in six 
cases ; left side in five cases. 

Of 47 cases of venous thrombosis without gan- 
grene there were : 

o 

Bilateral, 3 cases. 

Right side, 13 " 

Left side, 31 " 

Total, 47 cases. 

That is to say, combining together the cases of 

1 Huguenin, Correspondenzbl. sctnveiz. Aerzte, 1879, Xo. 15, 449, in 
which there -was also a tubercular meningitis ; Barberet and Chouet, Gaz. 
Hebdom., 1879, 2d series, xvi, 329; Vulpian, Rev. de Med., 1SS4, iv, 162. 

2 For a later important contribution to this rare sequel of typhoid see 
Osier, Recent Studies in Typhoid Fever, Johns Hopkins Hospital Reports, 
vol. v., and in the Journal of Nervous and Mental Disease, May 1896, p. 

295- 

3 Sumner, Boston Med. and Surg. Jour., 1SS3, cviii, 200. 

4 Xauwerck, Correspondenzbl. schweiz. Aerzte, 1879, 485, and Mayet, 
Ann. de la Soc. de Med. de Lyon, xxviii, 2d series, 1S80, p. III. 



78 SURGERY OF TYPHOID FEVER. 

venous obstruction, whether followed by gangrene or 
not, of 99 cases (52 -f- 47) there were : 

Bilateral, 7 cases. 

Right side, 23 " 

Left side, 69 " 

While in 61 cases (46 -f 15) of arterial obstruc- 
tion there were : 

* 

Bilateral, 12 cases. 

Right side, 25 " 

Left side, 24 " 

This extraordinarily even distribution in cases of 
arterial obstruction would seem to suggest that the 
cause is much more frequently embolic than has been 
hitherto believed, whereas in the venous obstruction 
the immense preponderance is on the left side and is 
probably due to the cause mentioned on page yy. 

The male genitals suffer very rarely as compared 
with the relative frequency in which the genitals in 
women suffer. Dr. Westcott, after a most extensive 
search, only found one case 1 in which the scrotum and 
the feet both suffered from gangrene. A few cases 
were noted in my earlier lecture. Barring the or- 
ganic destruction, no special result follows, except 
possibly hemorrhage, for one case is recorded of 
death from a hemorrhage of f§xxx from the scrotum. 2 

The female genital organs, however, suffer not in- 
frequently, probably from the neglected condition of 
many of the patients and the constant soiling of the 
parts, as a result of unconscious and unavoidable 
discharges, especially in women. I have found in 
all 21 cases, of which 17 followed typhoid and four 

1 Tunis, Univ. Med. Mag., 1889-90, ii, 195. 2 Murchison, p. 194. 



TYPHOID GANGRENE. /Q 

followed typhus. Fifteen cases were in young per- 
sons from seventeen to twenty-seven, except one 
child of five and five women of thirty-two years of 
a£e and over. In 18 of these cases there was <>an- 
orene of the labia extending" sometimes to the per- 

t> Ox 

ineum and the thigh, and even to the lumbar region 
and up the back, as in a case reported by Spillmann. 1 

The disorder manifests itself either as a distinct 
gangrene of the external genitals or by gangrenous 
ulcers forming in the vagina. The former occasion- 
ally is followed by complete closure of the vagina 
and retention of the menstrual flow, as in a case re- 
ported by Gueneau de Mussey, 2 in which an opera- 
tion resulted fatally, and in another, reported by 
Martin, 3 in which sloughing of the upper vagina and 
the entire cervix uteri occurred. 

The vaginal ulcers appear usually on the pos- 
terior wall and lead occasionally to recto-vaginal 
fistula. One is reported by Lebert, 4 in which, 
during convalescence in the seventh week, chill, 
fever, and diarrhea set in, and four weeks later 
the fistula was discovered by injection. It was 
situated in front of the hymen and was as large as a 
five centime piece. A month later she died of pelvic 
peritonitis. A second is reported by Liebermeister. 5 
It was caused by the sloughing of a large piece of 
the recto-vaginal septum, in mass. The large fistula 
thus produced healed without operation. A third 
case of vesico-vaeinal fistula and ^anorene of the 

o o o 

vulva appears in the present table reported by 

1 Arch. Gen., Feb. and March, 18S1. 2 Gaz. Hebdom. , 1S67, 652. 

3 Centralb. f. Gynekol., 1SS1. * Anat. Pathol., ii, 307. and PI. cxv. 

5 Ziemssen's Cyc, Amer. ed., vol. i, 184. 



80 SURGERY OF TYPHOID FEVER. 

Schick, * and in the fourth, my own case, both recto- 
vaginal and vesico-vaginal fistulse occurred. 

A resume of this unique case, of which I quote the 
earlier part from my former lecture, is as follows : 

Case II — Mrs. M. D. was under my observation 
in St. Mary's Hospital from 1873 to 1876, and is 
the only case I have found of both recto-vaginal 
and vesico-vaginal fistulse. Up to March, 1872, 
she was perfectly healthy, when, at the age of 
thirty-four, she had a severe attack of typhoid fever 
for four months following exhaustive nursing dur- 
ing her husband's fatal illness also from typhoid. 
About the fourth week the labia minora sloughed 
away to a large extent, and both urine and feces 
escaped by the vagina. In October, 1872, she was 
admitted to the hospital, under the care of my 
colleague, Dr. Grove, with two large vesical open- 
ings (separated by a slight bridge of tissue), which 
had destroyed the posterior part of the urethra and 
the floor of the bladder up to the uterus, and one 
rectal opening an inch in diameter, and ij£ inches 
above the anus. Dr. Grove operated on her three 
times unsuccessfully ; once on the rectal opening by 
the rectum, when he divided the sphincter, and twice 
by the vagina. From December, 1873, to Decem- 
ber, 1875, I did nine operations. Thrice unsuccess- 
fully I attacked the fistulse proper, when, becoming 
convinced that the attempt to close them was hope- 
less, with her entire consent, after a full explanation 
of the consequences of the operation, I proceeded to 
close the vagina. At first 1 attempted to preserve 
and utilize the remnant of the urethra, which gave 
me great trouble and necessitated several opera- 
tions ; but at the twelfth operation, December 28, 
1 875, I gave up the attempt, excised the useless 
urethra, and closed the entire vulval aperture by ten 

1 Wien. klin. Wochen., 1892, vi, 413. 



TYPHOID GANGRENE. 8 I 

silver sutures. The operation was a complete; success. 
At the time of the delivery of the Toner Lecture, 
nearly seven weeks after the final closure of the 
vulva, I stated that she; defecated, menstruated, and 
micturated entirely by the rectum, and without the 
slightest trouble. She rose usually once, sometimes 
twice, in the night, and micturated only five or six 
times during the clay. My greatest fear was that 
the feces, softened by the urine, would pass into the 
vagina or bladder and give trouble, but up to that 
time at least, none had arisen, and she was happily 
rid of the annoyance which had continued four years. 
Soon after this, however, a small fistulous opening 
appeared in the cicatrix, caused probably by the 
feces. This healed after a thirteenth operation, and 
when my lecture was printed (May, 1878) she had 
remained entirely well for over fifteen months. In 
the last four operations, instead of the usual sigmoid 
female catheter to empty the bladder I inserted the 
curved branch of a pocket-case male catheter into 
the bladder and the vagina through the anus and 
the recto-vaginal fistula, thus draining these cavities, 
while I drained the rectum below the eye of the 
catheter by an ordinary drainage-tube inserted into 
the rectum, lest the feces should be softened by the 
urine and then pass into the vagina. They answered 
admirably. The difficulty in obtaining a cure, I be- 
lieve, lay partly in the inherent difficulty of the case 
and partly in her deteriorated health ever since the 
fever. 

Her later history is as follows : 

Menstruation ceased in February, 1887, over 
eleven years after the closure of the vagina. Decem- 
ber 11, 1888, she again came to me complaining of 
pain in her rectum and vagina, and stated that the 
urine was intermittent, sometimes escaping and 
sometimes not. She told me that for the thirteen 

6 



82 SURGERY OF TYPHOID FEVER. 

years since the last operation she had been abso- 
lutely comfortable; that she was only obliged to rise 

about twice in the night to evacuate the rectum ; and 
<_> 

that neither the urine nor the menstrual flow, while 
it had continued, had irritated the rectum, nor, so far 
as her sensations went, had the feces annoyed her by 
gaining access to the vagina. By inserting a finger 
into the rectum, I found that the old fistula between 
the vagina and the rectum had so contracted that it 
would barely admit the point of my forefinger. This 
examination showed at once that a calculus had 
formed in the vagina, which acted like a ball valve. 
Of course I readily partly crushed it by means of 
a pair of curved forceps introduced through the 
rectum. The portion I secured uncrushed weighed 
70 grains and measured ^ by 5/£ of an inch. She 
made an entire recovery in three or four days. 

On May 7, 1896, she called again to say that while 
she had been perfectly comfortable for the seven 
years since the removal of the stone, three weeks 
before she called a small abscess had formed at the 
former outlet of the vagina, and that that morning 
the urine had commenced to dribble away. Exami- 
nation showed the orifice of the vagina firmly closed 
excepting at one small point just admitting a probe, 
through which some urine was escaping. Rectal 
touch showed that the recto-vaginal fistula was the 
same as before. I advised her to keep the parts 
clean and wear a napkin, and wait to see whether 
the small fistula would not close spontaneously. In 
two weeks this hoped-for result followed, and she is 
again entirely relieved of her distressing disability 
and has continued well up to the end of 1897. 

The case is particularly interesting, not only for 
its unusual character and its cause, but because I 
believe it was possibly the earliest case in which the 
urethra itself was entirely removed and the vagina 



TYPHOID GANGRENE. S$ 

closed, the rectum thus being made to serve the triple 
purpose of a reservoir for the urine, the menstrual 
discharge, and the feces. It is an encouraging fact 
that in any case requiring similar treatment, the later 
history shows that for twenty-one years she has only 
twice had the least trouble, once from a small calcu- 
lus forming- in the vagina and once from a small 
abscess forming in the cicatrix, which abscess 
spontaneously closed. Instead of being a constant 
source of disgust to herself and everybody about her, 
a hospital patient dependent upon charity, as she 
could not earn her daily bread, and a Pariah cut off 
from all society, she has been enabled to become 
self-supporting as a nurse, and to enter freely into 
her wonted social relations. 

Gangrene of the perineum or around the antes arises 
in a few cases in both sexes. In women it is gener- 
ally by extension of the process from the vulva. I have 
notes of nine men and six women, the sex not being 
given in two other cases. Excepting five cases, — one 
often, two of eighteen, and one each of twenty-one 
and twenty-two years of age, — they all occurred, when 
the age is stated, from thirty-nine to seventy-four 
years of age, later in life than most of the other 
sequels of typhoid. This is presumably due to the 
fact that in later life the nutrition of the perineum is 
apt to be less vigorous than in early life. Typhoid 
was the cause in 14; typhus in three. Excepting 
one in the second week, they all occurred also rather 
later than other cases of gangrene ; namely, from the 
third to the seventh week — in other words, during 
distinct convalescence ; and to this is probably due 
the fact that 1 1 recovered and five died, one from 



84 SURGERY OF TYPHOID FEVER. 

hemorrhage by sloughing into the rectum. In a 
number of cases the bones of the pelvis were involved 
as well as the soft parts, and this may have been the 
real origin of the trouble. This also probably par- 
tially accounts for the later occurrence of these cases. 
Most of the perineal cases resulted in perineal 
fistulae. Three fistulae were caused by necrosis of 
the pelvic bones or sacrum and nine by gangrenous 
ulcers, which sloughed not only externally, but in 
five certainly communicated with the rectum, and 
probably did so in others. The only case of primary 
invasion of the anal region I have found was com- 
municated to me by Dr. Betz, of Oakville, Pa., and 
well illustrates the sudden and extensive ravages 
which typhoid gangrene may produce. There can 
be little doubt, I take it, that such a case resulted 
from extensive thrombosis of the vessels supplying 
the tissues which sloughed. That the upper part of 
the rectum itself was saved is due, I suppose, to the 
escape of the main trunk of the hemorrhoidal arteries 
from participating in the thrombotic process. 

Case III. — " H. L., age ten, fell ill with typhoid 
fever August i, 1890. The remainder of the house- 
hold, consisting of his father, mother, a younger sister, 
and two servants, a man and a woman, soon were all 
victims of the same disease. Presumably there must 
have been some serious local cause. The boy's 
temperature rose as high as 105 , but nothing out of 
the common occurred until the end of the fifth week, 
when he complained of irritation around the anus, 
which parts were found to be only discolored. 
Within twelve hours after attention was thus first 
called to them the tissues in the ischio-rectal fossa 
separated from the surrounding tissues and dis- 



TYPHOID GANGRENE, 85 

charged. The rectum was relaxed and protruded. 
It was gangrenous and speedily separated some 
distance above the sphincters. Retraction then 
took place, and a formidable cavity was left. Urina- 
tion, strange to say, was not interfered with. The 
wound healed by granulation quite rapidly under 
a dressing of lint saturated with carbolized oil, 
dusted with iodoform. Fecal evacuations were in- 
voluntary, of course, but the greatest cleanliness 
was enforced. An apparatus was needful to retain 
the feces at first, but was laid aside by Decem- 
ber. During recovery regular dilatation of the anus 
was made lest cicatricial contraction should produce 
obstruction. His recovery was absolutely complete, 
not only as to general health, but as to control of 
the evacuations." 

Occasionally gangrene attacks very unusual re- 
gions or organs. Thus single cases are reported of 
gangrenous suppuration of the gland of Bartholin 
(Spillmann 1 ) ; of the tongue, with cyanosis of the face 
and great dyspnea (Gaston David 2 ); of the uvula 
(Freudenberger 3 ) ; of both ears after ergot, 5vj, 
had been given in six doses (Sanda 4 ) ; of the lips, in 
which a secondary staphylococcus septicemia, ensuing 
probably from carious teeth, destroyed life (Spill- 
mann 5 ). The cheeks are attacked more frequently, 
and noma or cancrum oris is noted in my table as 
having been observed nine times, and, as usual, is 
very fatal, five of the nine having succumbed, the 
result in one bein^ unrecorded. The luno-salso suf- 

1 Arch, Gen., March, 1SS1. 

2 Quelques Consid. sur la Gangrene Typhoide, These de Paris, 1SS3. 

3 Aertzlich. Intelligenzbl., 1880, xxvii, 7. 

4 Rev. Gen. de Clin, et de Therap., 1S92, vi, 401. 
Merc. Med., 1895, No. 13, 145. 



86 SURGERY OF TYPHOID FEVER. 

fered from gangrene in five cases, of which three 
died. As to all of these, there is nothing peculiar 
calling for more than their mention as indicating the 
protean manifestations of typhoid gangrene. 

I append the following case of sloughing of the 
face, which if not one of noma was at least akin 
to it. The notes were kindly sent me by Dr. J. N. 
Hall, of Denver, Colorado : 

Case IV. — " Hattie J., American, eight years old, 
together with a brother and younger sister had 
severe typhoid in 1889. Course of disease normal 
until thirteenth day, when considerable swelling of 
genitals occurred, but disappeared after a few days. 
On sixteenth day small bedsore on back, and two or 
three more on nineteenth day. Extensive passive 
congestion of lungs. On twenty-ninth day tempera- 
ture 103 , 'swelling of right sublingual gland' (as 
I have it noted), ' feeling like the parotid in mumps.' 
On thirty-third day discharge of pus from right ear, 
with appearance of black slough, size of five-cent 
piece, on right cheek, opposite right first lower molar. 
On thirty-fifth day this was one by two inches, and on 
thirty-sixth extended to corner of mouth. Severe 
hemorrhage (arterial) occurred on this day and on 
thirty-eighth day patient died." 

Treatment. — To the treatment which I advocated 
twenty years ago little can be added. The preven- 
tive treatment, such as good food, fresh air, the 
best hygienic surroundings is the most important. 
Should the heart flag, its action must be maintained 
at all hazards ; alcohol in liberal doses is perhaps the 
best remedy. Digitalis, strychnin, spartein, strophan- 
thus, and other cardiac tonics of the later pharma- 
copeia may be added. The body should be carefully 



TYPHOID GANGRENE, 87 

examined, especially those parts of it which experi- 
ence has shown likely to he attacked, pre-eminently 
the lower extremities, and in women, and especially 
girls, the genitals. The arms, neck, and head being 
exposed are much more likely to attract attention 
should they be attacked by gangrene than those 
which are covered by the bed-clothes {cf. Chapter 
IV). If baths are used, care should be taken that no 
mechanical injuries are inflicted, especially on the 
legs. Chapman's ice- and hot-water bags, alternate 
heat and cold, with very moderate friction and stim- 
ulating liniments, should be advised and the use of 
the constant current as a means of stimulating the 
collateral circulation, both in the deep as well as the 
superficial parts, will be of service. If gangrene 
is not only threatened, but actually sets in, the 
gangrenous parts should be kept as free as possible 
from infection by the use of antiseptic dressings. 

The question of operation naturally is one of 
the most important that is raised. In gangrene 
of the genitals, head, neck, or trunk, operation, of 
course, is limited to the removal of the dead and 
sloughing tissues and especially in the promotion of 
the utmost cleanliness, particularly in parts of the 
body soiled by urine, feces, or the menstrual dis- 
charge. Detergent washes and stimulating douches, 
the keeping of the rectum free from accumulated 
feces, and thorough and free incision of abscesses in 
the vicinity of the anus are to be especially com- 
mended. 

In the extremities, if amputation is necessary the 

time when it shall be done depends largely upon 

whether the gangrene arises from distinct obstruc- 
ts o 



55 SURGERY OF TYPHOID FEVER. 

tion by a palpable thrombus or embolus, or whether 
it arises in the peripheral vessels without such an 
appreciable mechanical obstruction of the main ves- 
sels. In the latter case, the line of demarcation is 
usually established quite early, and the disease is 
generally unlikely to advance beyond this line. 
Amputation, therefore, should be done as soon as 
the line of demarcation is well pronounced, and it 
may be done but little above this line, since there is 
no obstruction in the vessels higher up which would 
threaten the integrity of the flaps. 

In the cases where a distinct thrombus or an em- 
bolus has formed, however, the obstruction is very 
apt to extend farther and farther, as time goes on, by 
secondary thrombosis. At what level, therefore, the 
limit between the tissues which must necessarily die 
and those in which nature can still keep up a healthy 
life will occur, can not be stated definitely until the 
line of demarcation is well established. In a very 
few cases, even when gangrene seems inevitable, the 
patient may yet recover without gangrene. Two 
such cases are reported by Phillips l and Salles. 2 

But the facts obtained by a study of my two series 
of cases aid us very distinctly in deciding the level 
at which amputation should be done. When the 
clot extends only up to the popliteal, the leg may 
escape gangrene altogether ; and, should it follow, 
I have found it limited, in 21 cases, to the foot six 
times, to the lower half of the leg once, and to the 
upper calf in 14 cases. When the clot extended 
into the femoral, the gangrene extended to the upper 
calf in 1 1 cases and to the thigh in eight cases. 

1 Lancet, 1891, i, 1207. 2 Lyon Med., 1893, No. 3. 



TYPHOID GANGRENE. 89 

When the clot extended above Poupart's ligament 

the gangrene was limited, in 15 cases: to the fool in 
one, to the calf in eight, and extended above the knee 
in six. Amputation in these cases, therefore, should 
not be done, as a rule, until a well-defined and prob- 
ably final line of demarcation has been formed. 
When operating, the leg should be made bloodless 
by elevation and kept so by very careful digital 
compression. The Esmarch bandage, as pointed 
out by Quervain, should not be used, partly because 
it may injure the vessels of the stump and so favor 
a new arterial or venous thrombus, and partly 
because it may break up an existing venous throm- 
bus and orive rise to a dangerous embolus. To this 
I would add another evident objection : that the 
septic fluids in the tissues should not be forced into 
the oeneral circulation. The hemorrhao-e will be 
slight, since certainly the artery, and often both the 
artery and the vein, will be obstructed, so that the 
" muscles will look like meat soaked in salt and 
water, and there will be no oozing from the marrow 
of the bone." 1 

Ouervain's method of operating was both in- 
genious and useful. After forming an anterior flap, 
and before making the posterior flap containing the 
vessels of the lower thigh, he only disarticulated 
the bones at the knee joint ; next he dissected the 
femur loose for 12 cm. above the joint, and divided 
the bone ; then exposed the vessels and ligated 
them ; and last of all formed his posterior flap. 
The wisdom of ligating the artery before dividing it 
was shown by the fact that in the amputated part 

1 Drewitt, Lancet, 1890, ii, 1023. 



90 SURGERY OF TYPHOID FEVER. 

it was found to be filled with a loose clot, which 
would almost certainly have been dislodged by the 
manipulation if the flap had been made prior to 
ligation, and so have caused considerable hemor- 
rhage. Such patients have not a drop of blood to 
spare. 

As a general rule, therefore, it is best to wait for 
the line of demarcation, but the operation should 
not be deferred long after its appearance. If 
danger of septic infection or speedy exhaustion 
appear, amputate immediately at or above the 
probable limitation of the disease. The extension 
of the disease, if the femoral be free, will not be, in 
the majority of cases, above the tubercle of the 
tibia. If the femoral be involved, necessitating an 
amputation of the thigh, the resources and the safety 
of modern antiseptic surgery would lead us, in 
general, to amputate; but in some cases it may be 
a serious question whether expectant treatment and 
a relatively long subsequent amputation might not 
be less dangerous than an earlier operation. In 
two cases x amputation of both legs was followed by 
recovery. 

1 Butler, N. Y. Med. Rec., Sept. 28, 1889, 342; and Durand, Arch, de 
Med. et de Pharm. Mil., July, 1894. 



CHAPTER IV. 
TYPHOID AFFECTIONS OF THE JOINTS. 

Rheumatic Typhoid Arthritis. — Besides ty- 
phoid arthritis, properly so called, — which I shall 
shortly consider at length, — there are two other 
forms of arthritis which occasionally, but far less 
frequently, are connected with typhoid fever — viz., 
a rheumatic and a septic form of arthritis. While, 
like the usual typhoid arthritis, both may affect a 
single joint, more frequently they are polyarticular. 

Of the rheumatic variety, in the later series of 
cases, the case of Despaigne, 1 though the history is 
not entirely clear, was very probably an example. 
Multiple ankyloses were found after an interval of 
eighteen months. Three other cases are distinctly 
stated to be of this variety, and had a previous rheu- 
matic history. Freyhaus' case, 2 in which the knees, 
ankles, elbows, and wrists were involved, but recovery 
of all these joints followed, may be fully accepted as of 
the rheumatic variety. That of Balzer, 3 which proved 
fatal from a purulent arthritis of the left knee with 
non-purulent teno-synovitis of the left wrist, may 
also have been an instance. But this case probably, 
and still more certainly that of Robin, in spite of the 
opinion of the author, seems to me to be not so 

1 Lapersonne, Des arthrites infectieuses, p. 120. 

2 Berl. klin. Wochen., 1891, xlii, p. 1. 

3 Robin, Gaz. Med. de Paris, 1881, No. 40, p. 559. 

QI 



92 SURGERY OF TYPHOID FEVER. 

much rheumatic as septic in character. These, with 
those of Rendu z and that of Menard, 2 1 should class 
together under the next variety. 

Septic Typhoid Arthritis. — In the case of Robin 3 
there were purulent arthritis of the little toes and pus 
in the sheaths of their extensor tendons ; purulent 
arthritis of the knee-joints, of the right ankle, and of 
the knuckle-joint of the right middle finger, the pus 
again extending into the sheaths of the tendons of 
that wrist ; purulent arthritis of the right shoulder 
and of the left elbow, with suppurative periostitis of 
the left tibia and abscess around the larynx and 
trachea and the left costal cartilages. Could one 
draw a more striking picture of a septic case ? No 
other result than death could be expected. 

The two other cases, though only involving one 
joint, seem to have been septic. 

In Rendu's case, the patient died from a purulent 
arthritis of the right hip-joint with abscesses in the 
thigh and osteomyelitis, and the autopsy disclosed a 
purulent pleuro-pneumonia and nephritis. 

It is much easier now to understand these septic 
cases than twenty years ago, before bacteriology was 
born. They result from a mixed infection with the 
typhoid and the pyogenic bacteria. In the third case 
this is definitely assigned as the cause, the port of 
entry being the sacral bedsores. In fact, every case 
of typhoid fever has a possibility of sepsis, since, 
apart from the frequent boils and bedsores, the 
intestinal ulcers are always an open and possible 
door inviting such infection. Tripier 4 has especially 

1 Quoted by Wit/.el. 2 Soc. Med. des Hop., Jan. II, 1878. 

a Gaz. Med. de Paris, 1881, 559. 4 Lyon Med., 1888, p. 195. 



TYPHOID AFFECTIONS OF THE JOINTS. 93 

insisted upon the frequent, if not constant, origin 
of septicemia from the external ulcers. 

In Menard's case it is to be observed that a rare 
joint — the upper articulation of the sternum — was 
attacked, the pus soon reaching the anterior medias- 
tinum. Analogous to this one case of the later 
series are those of Fraentzel ' and Werner 2 in the 
earlier series. 

A septic arthritis in typhoid runs the usual course 
of similar septic inflammations, and has their fre- 
quently fatal termination in spite of all treatment ; 
all the more so in typhoid since it follows or ac- 
companies so exhausting a disease. There is nothing, 
in respect either of the symptoms or the treatment, 
to which I need call attention, except to the necessity 
for the most vigorous stimulation. But the occa- 
sional occurrence of such septic cases and their uni- 
formly fatal result should warn the physician to 
heed the very first complaint of pain in any part, 
especially if the complaint be made early in the case. 
It may be the beginning of a rheumatic or a septic 
case, which he may possibly be able to carry through 
safely. If not of either of these varieties, it may be 
the signal symptom of the usual typhoid arthritis, 
in which the danger is not of suppuration or even 
generally of ankylosis, still less of death, but of 
a totally unexpected complication — viz., dislocation, 
especially of the hip. 

1 Ein Fall von acuter Mediastinitis in Verlauf eines Ueotyphus, Berlin, 
klin. Wochen., 1874, xi, 97. 

2 Verbreit. sinuose Geschwiire auf der Brust, Perfor. voider Mittelfellraum.*, 
Plotzlich. Tod an Verblutung, Typhose Geschwiire im Darm., Med. Corresp. 
Wurttemb. aerztlich. Verein, Stuttgart, 1859, xxix, 76. 



94 SURGERY OF TYPHOID FEVER. 

Typhoid Arthritis Proper. — [a) Polyarticular 

Variety. — Typhoid arthritis proper may affect more 
than one joint, though the monarticular form, espe- 
cially in the hip, is far the most frequent and the 
most serious. 

In the second table, excluding cases involving the 
vertebrae, which are considered later, the polyarticu- 
lar cases involved: (i) Both the upper and the lower 
extremities in 3 cases — viz., wrist and knee, 2 ; 
elbow and both ankles, 1. (2) The lower extremi- 
ties alone in 6 cases — viz., both hips, 2 ; both ankles, 
2; hip and knee, 1; hip and ankle, 1. (3) The 
upper extremities alone in two cases — viz., both 
wrists, 1 ; shoulder and elbow, 1. 

Combining these together, it will be observed that 
the lower extremities were involved in nine cases as 
against five in the upper. 

Not one of the cases died ; a marked contrast to 
the six cases of the rheumatic and septic forms, of 
which four died. Even, therefore, a polyarticular 
arthritis does not seem to add to the danger of death 
in typhoid — a most comforting fact to the physician, 
the patient, and his friends. Even ankylosis is an 
infrequent result. Beside the case of Despaigne, 1 
already considered, in one case ankylosis of both 
hips followed a faulty posture, persisted in long after 
the fever. 2 This case recovered motion after forci- 
ble flexion under ether. In Clarke's case 3 ankylosis 
of the elbow persisted, very possibly for want of early 
passive motion. 

1 Lapersonne, Des Arthrites Infect., p. 120. 

2 Gibney, Trans. Amer. Orthop. Assoc, 1889. 

3 Jour. Amer. Med. Assoc, April, 1891, 473. 



TYPHOID AFFECTIONS OF THE JOINTS. 95 

In the earlier series three other cases of ankylosis 
were noted, making six cases of ankylosis out of 84 
cases of arthritis in the combined tables. 

In its symptoms, save that more than one joint is 
involved, the polyarticular form of typhoid arthritis 
does not differ from the monarticular ; and as the 
latter form, especially in the hip, is so important, 
this will be considered more fully. 

($) The Monarticular Variety. — The monarticular 
form of typhoid arthritis affects the larger joints, such 
as the elbow and shoulder, the ankle and knee, but 
above all the hip. The pain is usually slight, though 
sometimes very severe and prolonged. The swell- 
ing is generally readily observed in all joints except 
the hip and the shoulder, where it is probably ob- 
scured by the muscular masses about these joints 
combined with the tardy increase in the swelling. 
Usually the arthritis arises spontaneously, but occa- 
sionally from periostitis or necrosis extending into 
the joint. Pus rarely forms, and hence suppurative 
or fistulous openings are rare. 

In only one case, 1 in fact, of the 41 cases of the 
second series was there suppuration in any joint, 
that case involving the knee. This indisposition to 
suppuration is well shown in Dunin's case, 2 in which, 
though the infection was severe enough to produce 
abscesses of the buttock and hip, many furuncles 
and suppurative otitis media with arthritis of the 
right elbow and shoulder, these joints themselves did 
not suppurate. The result is, therefore, generally 
a gradual return to usefulness, although, in six cases 

1 Tarbox, N. Y. Med. Rec, Aug. 24, 1889, 209. 

2 Deutsch. Arch. f. klin. Med., 1886, xxxix, 369. 



96 SURGERY OF TYPHOID FEVER. 

I have found ankylosis. Of 84 cases, the lower 
extremities were affected in 70, the upper in only 
17, seven of the cases involving a joint in both ; for 
occasionally two large joints are affected at once. 
Arthritis, therefore, resembles other surgical febrile 
affections, such as gangrene, necrosis, etc., in affect- 
ing mainly the lower extremities, as do also throm- 
bosis and the ordinary edema. 

The frequency of these joint troubles is not very 
great. Murchison does not even name this com- 
plication, nor do any of our text-books, either on 
Surgery or Practice, except a few lines by Volk- 
mann, in Pitha and Billroth' s Handbuch. Giiter- 
bock, 1 Hellwig, 2 Parise, 3 and Friedheim 4 are the 
only authors who have treated them at all fully. In 
the literature of the last fifty years, which is practi- 
cally covered by my two series of tables, I have 
collected in all 84 cases involving the joints. That 
they are of great importance and demand our 
utmost attention will be seen at once when we con- 
sider that of the 84 cases named spontaneous dislo- 
cations occurred in 43 ; 40 times in the hip, twice 
in the shoulder, and once in the knee — i. e., more 
than one-half of all the cases of typhoid arthritis 
are followed by spontaneous dislocation, nearly all of 
which are in the hip -joint. 

Dislocation of the Hip-joint after Typhoid 
Fever. — These dislocations require more particular 
notice. They are analogous to the dislocations which 

1 Archiv f. klin. Chir., xvi, 58. 

2 Ueber die Affect, des Hiiftgelenks bei Typhus, Marburg, 1856. 

3 Archiv. Gen., 3d series, 1842, xiv, I. 

4 Ueber die Spontanluxation des Hiiftgelenks nach Typhus, Berlin Thesis, 

1885. 



TYPHOID AFFECTIONS OF THE JOINTS. 07 

have been observed in locomotor ataxia, the exanthe- 
matous lexers, hemiplegia, sciatica, and rheumatism, 1 

as pointed out by Stanley" in 1841. In one case it 
was noted that for three months before the typhoid 
attack the child had been suffering from ordinary 
coxalgia. 

Unfortunately, there are on record very few exami- 
nations of such joints post-mortem, and very few 
bacteriological examinations of the fluid in the joints, 
and these are generally either negative or reveal the 
presence of the pyogenic organisms. The only in- 
stances I have found are as follows : 

1. A patient of my own, in St. Agnes' Hospital, 
had an attack of suppurative arthritis of the knee- 
joint, arising during typhoid fever, which I operated 
on, and the aureus and albus were found in the cul- 
tures made by Dr. Bevan. Unfortunately, the notes 
of the case have been lost, but the bacteriological 
examination was the chief point. 

2. A case of typhoid fever, under the care of 
Professor Hare and Dr. Thomas G. Ashton at the 
Jefferson College Hospital, which 1 saw with them. 
She was a girl of sixteen, admitted on January 16, 
1897, with a temperature of 105. 3 . She made a 
good recovery and was discharged from the hospital. 
In the fifth week swelling and some pain were ob- 

1 Spontaneous luxation has been observed after scarlatina by Dittel 
(Oester. Zeitschr. prakt. Heilk., 1861), Seinton (Rev. d"Orthop., 1892,354), 
Kirmisson (Bull, et Mem. Soc. de Chir. , 1894, xx, 213), Eisendrath (Annals 
of Surgery, Oct., 1897, 451) ; after acute articular rheumatism by Verneuil 
(Bull, et Mem. Soc. de Chir., 1883, 781), Seinton {Joe. cit.'), and Kirmisson 
{Joe. cit.) ; and after influenza by Eisendrath Joe. cit.). 

2 On dislocation, especially of the hip-joint, Med. Chir. Trans., xxiv, 123. 
See also Malgaigne, Fract. and Disloc, Paris, ii, pp. 218-226, SS2-8S7. 

3 Phocas, Gaz. des Hop., 1894, Xos. 132 and 135. 

7 



98 SURGERY OF TYPHOID FEVER. 

served in the left leo-, the swelling extending from 
above the knee to the ankle, but she recovered from 
this without any especial trouble. Soon afterward, 
however, the swelling returned, and was accom- 
panied by severe pain and great tenderness, espe- 
cially in the knee-joint, so that motion was impos- 
sible. I saw her on April 22, 1897, and again on 
June 1 8th. On both occasions the knee was aspir- 
ated, but the fluid proved to be entirely sterile. The 
arthritis resulted in ankylosis in marked flexion, 
which will require later operative treatment. 

3. Klemm * reports the case of a girl, age fourteen, 
who was ill with typhoid for fourteen weeks, and who 
had lain for two months with the knees almost touch- 
in a- the thorax. An iliac dislocation of the left 
hip-joint resulted. An abscess formed over the 
trochanter, which, on being opened, gave exit to a 
reddish turbid fluid, like that of an old hemorrhagic 
hydrocele. The trochanter was bare and eroded. 
Facial erysipelas followed, and she died nineteen 
days after admission. At the post-mortem typical 
typhoid lesions were found. The capsule of the hip- 
joint was much distended but without any fluid in it. 
The fluid of the abscess contained the typhoid bacil- 
lus. The hip-joint does not seem to have been ex- 
amined bacteriologically. 

4. Schiiller 2 . found, in cases of inflammation of the 
hip- and knee-joints after typhoid, " in the serous fluid 
only round cocci and some streptococci, and single 
small bacilli resembling those which are found not 
infrequently on the intestinal surface, to which atten- 

1 Arch. f. klin. Chir., 1893, xlvi, 862. 

- Witzel's Gelenk- und Knochenentzund., p. 52. (No reference is given.) 



TYPHOID AFFECTIONS OF THE JOINTS. 99 

tion was first called by Klebs, but which, however, 
Koch, Gaff ky, and others do not regard as absolutely 

characteristic of typhoid. The bacilli now regarded 
as the typhoid bacilli, — the ovoid form first described 
by Eberth, — I could not find in the contents of the 
joint. In another case of typhoid which 1 had to 
examine during- life, I could not find any micro- 
organisms." 

5. Danlos and Strauss 1 report the case of a man 
of twenty-nine whose fever, even at the beginning, 
was accompanied by pain and swelling in the knees 
and elbows, and on the fifth day the patelke were 
"floating" from the effusion; soon purpuric spots 
appeared but no taches rouges. He died on the 
eighteenth day, his articular disease not having 
materially changed. The day before his death the 
right knee was punctured, the fluid found being 
apparently clear synovia. At the necropsy the 
lesions of typhoid were found. The right knee-joint 
was healthy ; cultures from the fluid in the joint and 
of the blood were sterile. 

6. Orloff 2 injected cultures into joints in dogs and 
rabbits, and reported that this was followed by swell- 
ing in twenty-four hours, with hemorrhage in the 
synovial membranes. A thick, tenacious, turbid 
fluid was produced in the joints, which later became 
more distinctly purulent. Microscopically, there were 
found pus-corpuscles, and in the earlier days after 
the injection, typhoid bacilli. 

This last result may possibly be the explanation 
of the impossibility of finding the bacilli in the joint 

1 Soc. Med. des Hop., 1887, 3d series, iv, 35. 

2 Centralbl. f. Bakteriol., 1890, 366. 



IOO SURGERY OF TYPHOID FEVER. 

affections in man, at least in some cases. Having 
done their malign work, they may have disappeared. 

Grancher, 1 however, obtained from a teno-synovitis 
the typhoid bacillus. 

The result in these five cases in man and one 
series of experiments in animals must leave us in 
doubt as to the role of the bacillus of Eberth in the 
joint affections of typhoid. The future must afford 
us the data for a certain conclusion. The need for 
such bacteriological examinations, at the best very 
rare, is most evident. 

It is to be hoped that this hiatus in our knowledge 
will be filled before long, especially as it is so easy 
to obtain the fluid by aspiration, an operation in 
itself desirable to prevent dislocation. But though 
we are still largely ignorant of the bacteriology of 
the joint effusions, yet from the analogy of the 
other tissues to which I have alluded it is probable 
that the bacillus will be found to have invaded the 
joints also, and possibly later to have died out. The 
irritation caused by the bacilli or their toxins will 
readily account for the slow but steady accumulation 
of fluid in the joint. Parise 2 has shown experiment- 
ally that artificial distention of the hip-joint will 
produce a posterior luxation. That the capsular liga- 
ment will stretch more readily from the slowly in- 
creasing distention of disease, as compared with the 
rapid distention in experimental cases, is evident. 
I well remember the astonishment and incredulity 
I felt twenty years ago, when I first encountered a 
case of dislocation of the hip-joint alleged to be due 

1 Bull. M6d., 1892, vi, 1271. 

2 Arch. Gen., 3d series, tome xiv, p. 1. 



TYPHOID AFFECTIONS OF THE JOINTS. 101 

to typhoid fever. But incredulity had to change to 
belief, as I found case after case in undoubted rela- 
tion to the fever as a cause, and the more than two 
score cases now collected leave no room to doubt 
either the fact or the pathological explanation. 

The cause and symptoms of the trouble may now 
be considered at some length. 

Usually in the period of convalescence following, 
therefore, the prolonged exhaustion, there arises a 
subacute synovitis, with a gradual serous distention 
of the capsular ligament, which, having reached a 
certain point, may slowly subside, and no further 
evil follow. In five cases, however, this burst exter- 
nally, producing sinuses, but in only two of them was 
the discharge purulent. In both of these there was 
also necrosis of the bones. The main result is a slow, 
generally unperceived, elongation of the ligaments, — 
e. g. y of the hip, — with perhaps also a swelling of the 
so-called eland at the bottom of the acetabulum. 
This distention will spend its force mainly poste- 
riorly, since the inverted Y-ligament reinforces the 
capsular ligament in front. Given this condition, 
the slightest force will dislocate the head of the 
femur, usually upward and backward on the dorsum 
of the ilium. In one case a fall to the Moor produced 
it, in three others turning over in bed, and twice the 
lifting of the patient in the arms from one bed to 
another. But in all the other 34 cases no cause was 
assignable, and it is, therefore, likely that it was 
mere muscular contraction, which becomes more 
vigorous as health gradually returns — the very time 
when these dislocations most often occur. In one 
of the shoulder cases a subcoracoid luxation was 



102 SURGERY OF TYPHOID FEVER. 

caused by the patient's assuming the erect posture. 
Gravity had here probably some influence, together 
with the muscular exertion. The dislocation of the 
knee was also posterior, the result doubtless of the 
muscular traction of the hamstrings. 

Typhoid was noted as the preceding fever in 15 
and typhus in 7 of the hip cases of the earlier series. 
In the later series typhoid is the sole preceding fever 
in all 13 cases of dislocation. Sex has not a very 
marked predisposing influence, for of 35 cases 19 
were males and 16 females. The age at which they 
occur is much more noteworthy : 22 were under fifteen 
years, 10 from fifteen to twenty, 1 was thirty, 1 was 
thirty-five, and 1 was sixty-one years old ; that is, 
32 out of J5 were under twenty years old. The 
analogy to coxalgia, it will be observed, is, therefore, 
very marked. Usually they were single dislocations, 
12 being on the right side and 10 on the left; but in 
3 cases dislocation of both hips occurred. 

From the apathetic condition of the patient in 
some cases, the subacute nature of the lesion, the 
absence or slightness of the pain, or in some cases 
its great severity which precludes any movements 
and therefore any thorough examination, the mask- 
ing of the swelling by even the wasted muscles about 
the joint, and, above all, the want of knowledge of 
any danger or even any possibility of the dislocation, 
and therefore the neglect to examine the parts thor- 
oughly, it is not surprising that this threatening evil 
should have been often unobserved. In 16, — that is, 
nearly one-half — of the cases it is distinctly stated 
that the actual dislocation was the first fact observed, 
and in most of the others this is probably true. 



TYPHOID AFFECTIONS OF THE JOINTS. 103 

The date at which the dislocation was, atleast, ob 
served was generally after the third week. One 

case occurred in the first week, 4 in the second, 4 in 
the third, and 17 in the fourth week or later — that is, 
during distinct convalescence. Pain was experienced 
in at least 25 cases, and probably in more. Usually 
it was not severe, nor was it always strictly localized 
in the hip, but sometimes extended to the entire leg. 
In only 3 cases was it referred to the knee, thus dif- 
fering- markedly from the well-known coxalgic knee- 
pain. Swelling is only distinctly stated in peases, 
though probably present here as in other joints, 
but either unobserved or often unrecorded in the 
brief statements I have found. The variety of the 
dislocation is not named in 12, but as in all the other 
28 it was iliac, there is eood reason to believe 
that this is probably practically always the case. 
One case, however, is recorded of an obturator dis- 
location. 1 Shortening is recorded in 18 cases, and 
where the amount is named was generally i 1 /^ to 
two inches. In 6 cases the rotation was inward, in 
2 outward, and in 2 of the 3 double dislocations both 
legs were rotated in the same direction, — that is, right 
or left, — thus producing a peculiar deformity when 
compared with the apparently reversely rotated 
body. The head of the bone in 4 cases was freely 
movable in all directions. This mobility of the head 
and the singular diversity in the rotation of the limb 
are additional reasons in favor of the distention 
theory of its pathology. 

As to treatment, in consequence of the relaxation 

1 Ftiedheim, Ueber die Sponlanluxationen des Huftgelenks nach Typhus, 
etc., Berlin Thesis, 1SS5. 



104 SURGERY OF TYPHOID FEVER. 

of the ligaments of the joint, reduction is generally 
easy when the luxation is discovered early, but if the 
discovery or treatment be tardy, it is always difficult 
and often impossible. In 17 cases reduction was 
successfully accomplished, 13 times by manipulation, 
twice by extension, and twice by both means. In 
1 1 cases reduction was not effected, — though in one, 
after extension for a week, two attempts at reduction 
were made under ether by so good a surgeon as 
Kronlein, — and in 1 2 the result is not stated. In the 
case of obturator dislocation two osteotomies gave 
a favorable result. In three cases seen late, as pro- 
gression with a high shoe was quite satisfactory, 
reduction was not attempted. Only three cases of 
recurrence of the luxation are noted, a rather sur- 
prising fact in view of the relaxation of the distended 
tissues ; but its possibility should be borne in mind 
and guarded against by the use of a stout binder 
surrounding the hips or by a plaster-of-Paris spica 
of the hips and pelvis. No snap is heard on reduc- 
tion, all tension and suction-power of the joint being- 
lost. Even after reduction the leg may be somewhat 
longer than the other, owing, probably, to the disten- 
tion, to the swollen articular gland, and possibly, in 
old cases, to interstitial changes in the head and neck 
of the femur and in the acetabulum. 

The question of prophylaxis is perhaps the most 
important of all, and the indications are clear. First, 
a careful watching and repeated examination of the 
hip-joint, especially in children, to detect pain or any 
effusion. 

Physicians, having learned that dislocation of the 
hip is a possible, even though an infrequent, result 



TYPHOID AFFECTIONS OF THE JOINTS. 105 

of typhoid fever, should heed the first complaint of 
pain, even in a semi-comatose or delirious patient, 
particularly if the age be under twenty. Even 
if the patient does not complain of pain, the hip- 
joints should be examined in young persons 
from time to time to detect the first possible sign 
of effusion, and therefore any danger of disloca- 
tion. 

If any exist, the position of the leg becomes of the 
greatest possible importance. As adduction and 
internal rotation favor spontaneous dislocation, the 
leg should be kept in abduction and external rotation. 
The first indication is easily fulfilled by two lateral 
sand-bags, which may be bridged across in front at 
intervals by a bandage, to keep the leg at rest, 
or by lateral splints. The foot may be kept in 
external rotation by bandages or adhesive plaster 
fastened to the external sand-bag or splint. Gentle 
extension by a weight and pulley would be useful in 
steadying the limb. If the effusion threatens to pro- 
duce dislocation, aspiration under the strictest anti- 
septic precautions is a safe and efficient means of 
prophylaxis. If pus is found, — as is almost never the 
case, — the joint should be opened and treated accord- 
ing- to the existing conditions. In one case 1 the 
upper epiphysis of the femur became detached, and 
later was removed. In another, 2 the edge of the 
acetabulum necrosed. 

The two following unpublished cases of dislocation 
of the hip after typhoid are the only ones I have ever 
seen personally. For the earlier notes of the first 

1 Rivington, Lancet, 1890, i, 901. 

2 Weil, Prager med. Wochen., 1878, 61. 



106 SURGERY OF TYPHOID FEVER. 

case I am indebted to her physician, Dr. H. W. Rihl, 
of Philadelphia. 

Case V. — In April, 1891, Miss J., age eighteen, 
presented herself at my clinic at the Orthopedic 
Hospital to see if anything could be done to remedy 
her lameness. Over two years before, on Decem- 
ber 14, 1888, at the age of sixteen, she fell ill with 
typhoid fever and was treated by a homeopathic 
physician. January 2, 1889, near the end of the 
third week, she w r as suddenly taken with two 
convulsions, when her father, in alarm, sent for 
Dr. Rihl, who writes me : " It was a well-marked 
case of typhoid from my first visit, on which 
occasion she had constant low delirium and sleep- 
lessness; not having slept any for forty-eight hours. 
It varied from ordinary typhoid in three striking 
particulars: the convulsions occurring at the end 
of the third week ; aphasia, or perhaps, more 
precisely, amnesia, and the great pain in the 
right thigh aggravated and incessant for many 
days, the origin of which was not suspected until 
after her recovery. I doubt very much, even if 
I had understood at the time the cause of the 
pain, whether I would have been able to apply 
any apparatus, as her pain was agonizing, and 
she resisted every touch of the limb. I see a 
record on my book, of January nth, 'left knee 
rigid, painful, and flexed ' ; on re-reading this, my 
first impression was that I had made a mistake in 
writing ' left,' meaning ' right,' but in thinking over 
the matter I remember distinctly that it was a long 
time before I discovered the real seat of pain, as in 
consequence of her amnesia and delirium we could 
scarcely acquire any information from her until some 
days after, when she pointed to the right thigh. I 
have no record of the time of the commencement 
of the amnesia ; it was certainly before January 



TYPHOID AFFECTIONS OF TUP JOINTS. 107 

11th. The fever, as you will perceive by referring 
to my daily record, was January 12th, 104 , and 
January 1 8th, 106 , hut these high temperatures 
continued but a few hours, antipyrin acting very 
satisfactorily in almost every instance in rapidly 
reducing the temperature. For so grave a case, 
the average temperature was remarkably low." By 
January 1 ith she could speak a word or two ; on the 
23d for several days her speech had slowly improved, 
and by the 30th speech had entirely returned. By 
February 21st she was able to be up each day, and 
on May 1 6th Dr. Rihl ceased his attendance. Mean- 
time the pain in the thigh was at times noted as 
" very severe," and at other times "less," and it is 
curious to note that the pain seemed not seldom to 
increase or diminish with the decree of the fever. 

In November, when Dr. Rihl returned from his 
holiday in Europe, he first found the explanation of 
the pain in the right thigh, there being an iliac dis- 
location with marked shortening. No intervening 
accident had occurred. 

When she presented herself at my clinic the dis- 
location was evident at a glance. The right leg 
measured, from the internal malleolus to the anterior 
superior spine, 28 inches, on the left 30^ inches, but 
there was practically no difference in the circumfer- 
ence of the calf or the general development of the 
lame lesf. As the dislocation had existed for over 
two years, and a high shoe fairly well remedied the 
lameness, I advised that no attempt at reduction 
should be made. 

Case VI. — R. McD., aged sixteen, consulted me 
November 4, 1897, at the Jefferson College Hos- 
pital. She had had typhoid fever in March, 1896. In 
the third week of the fever she suffered from a great 
deal of pain in the right hip and a little in the knee, 
which continued for four weeks. Movement of the 
leg caused pain in the hip. When she got out of 



IOS SURGERY OF TYPHOID FEVER. 

bed she found she was lame, as the right legf was 
shorter than the left, and was stiff at the hip, but 
not at the knee. The shortening I found to be two 
cm., and the head of the femur was subluxated on 
the edge of the acetabulum. I made four attempts, 
under ether, to reduce the dislocation, but finding 
this impossible I ordered a cork sole for this side. 

Case VII. — Dr. Swett, of Connecticut, has kindly 
given me the notes of a third case of dislocation of the 
hip. The patient, a woman aged thirty-five, lived ten 
miles away, so that he was unable to see her often, 
though the high temperature and extremely active 
delirium made frequent visits desirable. The nurse 
called his attention to the pain in the hip at his last 
visit, in November, 1892. Both he and another 
physician who saw her three months later, thought 
at first that it was due to sciatica. The pain arose 
in the beginninor f j-]^ s { x th week, the second week 
of convalescence. The dislocation was iliac. Two 
unsuccessful attempts under ether were made to re- 
duce it. 



CHAPTER V. 

TYPHOID AFFECTIONS OF THE BONES. 

Excepting the laryngeal complications and sequels 
of typhoid fever, the most frequent are those con- 
nected with the bones. In my Toner Lecture I 
gathered 69 cases. But since then, owing to atten- 
tion having been called to the subject, the recorded 
cases have become much more numerous, so that 
we have collected from the literature of the last 
twenty years 168 cases, making 237 in all, as a basis 
of my analysis. Unfortunately, no analysis in the 
particulars not recorded in the earlier lecture, as 
printed, can be made, since the detailed tables have 
not been preserved. This is the less to be regretted, 
since of the earlier series only 37 of the cases fol- 
lowed typhoid and four followed typhus, whereas the 
entire number of cases of the second series — 168 — 
are from typhoid, making in all 205 cases of all 
kinds following typhoid. The entire absence in the 
later table of bone disease following typhus and the 
almost entire absence of typhus cases in the other sur- 
gical sequels, is doubtless partly due to improved san- 
itary conditions prevailing all over the civilized world, 
which have well-nigh banished true typhus fever. 
But it is very largely due also to a more accurate 
diagnosis of typhoid itself, and a more accurate use of 
laneuacre, thus vindicating what I said twentv vears 
aoo, that manv of the cases recorded and, therefore, 

109 



IIO SURGERY OF TYPHOID FEVER. 

necessarily tabulated as following "typhus" fever, 
were really sequels of typhoid or "typhus abdomin- 
alis." If, for brevity or through carelessness, the 
author omitted the adjective, I did not feel at liberty 
to go behind the record, and, consequently, I was 
obliged to tabulate it as typhus, though often con- 
vinced, from the history and symptoms, that the case 
was really one of typhoid. To take such liberties 
with the records of cases would expose one to other 
possible inaccuracies, and would impair confidence in 
the accuracy of the later author. It is greatly to be 
regretted that, especially in Germany, the words 
" typhus," " typhosus," etc., are still used, instead of 
"typhoid," or "enteric" to designate the fever. 

Pathology. — The causes to which twenty years 
aoo I attributed the necrosis of bone which was at 
that time by far the most frequently recorded sequel 
among the bone lesions (50 out of 69 cases), were 
two : First, thrombosis, or, in some cases, embolism ; 
and, secondly, absolute inanition, or want of nutri- 
tion. But modern bacteriology, which did not exist 
in 1876, has rendered these views almost entirely 
untenable, and gives the first and by far the most 
important place to the typhoid bacillus. 

It is doubtful whether inanition plays any role 
whatever in producing any of the typhoid diseases 
of bone, though it is possible that in a patient 
whose nutrition was at a very low ebb it might lead 
to necrosis, especially if any injury were inflicted on 
a subcutaneous bone. The poor nourishment of 
the bone would be a predisposing, and the injury 
the exciting, cause of the necrosis. 

Thrombosis, or occasionally embolism, can not be 



TYPHOID AFFECTIONS OF THE BONES. mi 

so entirely dismissed as a possible, though most 
probably a rare, cause of necrosis after typhoid. . For 
example, in the Toner Lecture (Fig. i) I have given 
the history and reproduced the illustration of a wide 
necrosis of the frontal, parietal, and sphenoid hones, 
traced directly and positively to occlusion of the 
meningea majora. In the chapter on gangrene (pp. 
$3 and 86) I have pointed out the fact that, in a num- 
ber of cases of gangrene in the anal and perineal 
regions, the bones as well as the soft parts were in- 
volved, and that noma or cancrum oris was recorded 
nine times, of which five, and possibly six, were 
fatal. One can readily imagine that the gangrene 
of the soft parts in such a case might easily extend to 
the bones. This is especially true in cases of gan- 
grene of the lips and cheeks, and, accordingly, 
among the diseases of bone in the second series we 
find cases of extensive necrosis of the jaws, often 
associated with oan^rene or slouehincr of the 
cheeks. It is most probable, it seems to me, in 
such cases that either a single thrombus, or occa- 
sionally an embolus, of a main trunk, or more likely 
a wide-spread vascular arrest in many smaller 
vessels (as described under Gangrene and under 
the Cerebral Complications of Typhoid Fever), is 
the cause alike of the destruction both of the bone 
and the adjacent soft parts. Thus, in M ears' case ' 
there was a sequestrum removed consisting of the 
greater portion of the body or alveolar process of 
"the upper jaw, with parts of the nasal, malar, and 
palatine processes, and the teeth as far forward as 
the canine were lost; in Franklin's case 2 there was 

1 Med. Times, Phila.. Aug. 28, 1SS0, p. 608. 2 Lancet, 1897, i, 553. 



112 SURGERY OF TYPHOID FEVER. 

necrosis of the whole alveolar process of the left 
upper jaw, with destruction of the cheek (noma) ; in 
Lawton's case, 1 with necrosis of the left upper jaw 
there was gangrene of the left lower eyelid and 
cheek, and the orbital contents were all loosened 
from the bone ; and in Alexander's case, 2 with 
necrosis of the upper jaw there was extensive gan- 
grene of the mucous membrane of the mouth. 

In only two cases was the lower jaw involved ; 
one 3 with a sequestrum extending from the canine 
tooth to the angle of the jaw. In the other, 4 on the 
twenty-first clay circumscribed gangrene of the 
lung occurred, on the sixty-fifth day parotitis, and 
on the seventy-first day necrosis of the angle of 
the lower jaw. In spite of all these catastrophes, 
the patient, a young man of twenty-six, recovered. 

While thus it is possible that the two causes which 
twenty years ago I deemed most potent still should 
be deemed to have some influence, the real factor, 
in which inheres practically the chief power for mis- 
chief, is the specific cause of typhoid fever — the 
bacillus discovered by Eberth in 1880. In the in- 
troduction to these studies on the surgery of typhoid 
fever I have fully discussed the occasional pyogenic 
property of the bacillus of Eberth — a property 
which no one, in the light of the most recent re- 
searches and experiments, can doubt. In no one ot 
the various complications and sequels under con- 
sideration is this pyogenic power more strikingly 
shown than in the bones. All of the earlier cases, 

1 Lancet, 1879, '> 685. 2 Breslauer aertzlich. Zeitschr., 1887, 271. 

3 Heath, Med. Times and Gaz., Dec. 18, 1869. 

4 Eisenhart, Munch, med. Wochen., 1886, xxxiii, 163. 



TYPHOID AFFECTIONS OF THE BONES. I 13 

and man)' of the 168 cases which we have collected 
in the later table, occurred before the bacillus of 
typhoid was known. Its presence has only been 
sought for occasionally, for the larger number of the 
cases have occurred in the practice of persons 
whose taste for knowledge or whose opportunities 
led them only to record the actual practical facts and 
not to investigate the scientific causes underlying the 
facts. There are, therefore, only recorded in the 
later table 51 cases in which a bacteriological exam- 
ination was made. In 13 the pyogenic bacteria were 
found ; in all the other 38 the bacillus of Eberth was 
found. In many cases it was not stated whether it 
was found in pure culture or not, — an'd possibly in our 
table the word ''pure" may have been omitted by 
oversight, — but in 14 of the ^S it is distinctly stated 
that the bacillus was found in pure culture. In one : 
the colon bacillus was found associated with it, 2 and 
was responsible for the presence of gas in the pus ; 
and in one 3 the aureus and citreus were also found. 
In a number of cases bacteriological investigation, at 
a later date, after operation, showed that a subsequent 
infection with the ordinary pyogenic bacteria had 
taken place after the operation. 

Still more strange is the fact that in a number of 
cases with an open sinus for months and even years, 
and, therefore, one would think, with an almost in- 
evitable ordinary pyogenic infection, there has been 
found a pure culture of the bacillus of typhoid. 

1 Klemm, Archiv f. klin. Chir. , lviii, Heft 4. 

2 Dehu (Etude sur le role du bacille d' Eberth dans les complications 
de le fievre typhoide, These de Paris, 1893) states that the colon bacillus 
has never been seen in bone abscess. Klemm's case has been reported 
since then. 3 Parsons, Johns Hopkins Hosp. Rep., vol. v. 



114 SURGERY OF TYPHOID FEVER. 

Thus, Parsons l reports a case in which, seven 
months after the fever becran and three months after 

o 

an incision over the ribs resulting in a persistent 
sinus, the discharge showed a pure culture of the 
bacillus of Eberth. In Chapter II, page 19, 1 have 
o-iven several other instances, in some of which no 
added infection by the ordinary pyogenic bacteria 
occurred, even after years. 

It has been suggested that there may have been a 
mixed infection of the staphylococcus and the typhoid 
bacillus, of which the pyogenic organism was the 
active agent in causing the suppuration, but that the 
staphylococcus had died out, leaving the typhoid 
bacillus alone. 

The experiments of Klemm 2 would seem to sup- 
port this view. Pure cultures of the typhoid bacil- 
lus and the staphylococcus aureus were injected into 
rabbits, either simultaneously or at an interval of a 
week. An osteomyelitis was set up in each case, 
cultures from which showed only the aureus and 
none of the typhoid organisms. 

But the experiments of Dehu, 3 Vincent, 4 Vaillard, 5 
and Dmochowski and Janowski, 6 a most painstaking 
series of observations, especially the last, seem un- 
questionably to establish the fact that instead of a 
lesser viability the staphylococcus has a greater ; 
that when mixed with the bacillus of typhoid in a 
mixed infection the bacillus soon dies, leaving the 
staphylococcus in possession of the field. If, there- 

1 Julius Hopkins Hosp. Rep., v, 407. 2 Arch. f. klin. Chir. , Bd. xlvi. 

3 Le role du b.icille <T Eberth dans les complications de la fievre typhoide, 

These de Paris, 1893. 4 Ann. de 1' Institut Pasteur, 1893, vii, 141. 

5 Grancher, Bull. Med., 1892, vi, 1273. 

6 Ziegier's Beitrage, 1895, xvii, 221. 



TYPHOID AFFECTIONS OF THE BONES. 115 

fore, a pure culture of the typhoid bacillus is found 

in a suppuration after typhoid, it is very unlikely that 
the staphylococcus ever existed there. 

In marked contrast to its behavior when mixed 
with the staphylococcus, the bacillus of Eberth and 
the streptococcus both grow luxuriantly together. 
But, as I have already shown, the so-constant pres- 
ence of the bacillus of Eberth in pure culture in 
the pus from osseous and other lesions in the 
human subject; the fact that Ebermeier 1 has found 
a pure culture of the bacillus as early as the tenth 
and the thirteenth day of the disease (two cases in 
which the date was too early for the pyogenic cocci 
to die out) ; the cases quoted on pages 19 and 26, of 
long-continued existence of the typhoid bacilli alone 
in suppurative lesions, and the many experiments re 
ferred to on page 42, proving that the bacillus alone 
does actually produce inflammation and suppuration 
in bone ; — seem to set at rest the theory just alluded 
to. One positive case in which the typhoid bacillus 
has actually produced suppuration in animals is worth 
a dozen in which, in man, the suppuration may have 
been due to a presumed pyogenic organism, which, 
if it ever existed, has disappeared. The same argu- 
ment which is used in the chapter on the Cerebral 
Complications of Typhoid applies here. The cases 
are too numerous to be all classed as mistakes. 

The existence of a mixed infection and a pure 
typhoid infection are not exclusive the one of the 
other. Both may be true in different cases, and 
while the proof is decidedly in favor of the view that 
suppuration in bone is usually due to the pyogenic 

1 Deutsch. Archiv f. klin. Med., 18S0, xliv, 1 *o. 



Il6 SURGERY OF TYPHOID FEVER. 

property of the typhoid bacillus, yet there are doubt- 
less cases in which a mixed infection has occurred. 
After a careful examination of the subject, that is 
the view of Chantemesse and Wiclal, 1 who ascribe 
the osteomyelitis of typhoid to both pure and mixed 
infections. 

That the bones offer a peculiarly inviting field for 
the ravages of the typhoid bacillus, and especially 
for its late ravages, often not weeks, but months and 
years after the attack, has been explained of late by 
the discovery of two facts : first, the remarkable vi- 
ability of the typhoid bacilli in general (p. 19) ; and, 
secondly, their especial viability in the bones (p. 26). 

Being so tenacious of life in the adverse condi- 
tions in which their prolonged vitality has been 
proved, it is not surprising that in the bones them- 
selves, under more favorable conditions, they should 
be capable of living and doing mischief for a long 
time. 

As long ago as 1 872, 2 Ponfick noted and described 
the remarkable changes in the spleen and the bone- 
marrow in typhoid. After the bacillus of typhoid 
was discovered in 1880, it was especially sought 
for in the spleen and in the bone-marrow, and it 
was soon shown that of all the organs these two 

and the gall-bladder are its favorite seats, and that 
<_> 

especially in the bones the bacilli exist in the largest 
numbers and linger the longest. 

Quincke, 3 in nine post-mortems, found the bacillus 
eight times in the marrow of the ribs and once in 

1 Bull. etMem. Soc. Med. des Hop., 1893, x > 779- 

2 Virchow's Archiv, lvi, 534 and 1874, lx, 153. 

3 Berlin, klin. Wochen., 1894, No. 15. 



TYPHOID AFFECTIONS OF THE BONES. I 1/ 

the bones ol the extremities. Wissokowitsch ' has 
called attention to the frequency of the infection of 
the hone-marrow by the typhoid bacilli, and ascribes 
to this the frequency of the bone lesions of typhoid. 
Chantemesse and.Widal 2 inoculated rabbits and 
found the bacilli only in the bone-marrow. I )mo- 
chowski and Janowski 3 have shown the same facts. 

But besides cases in which the bacilli, though 
present, had not as yet produced any disease in the 
bones, there are a large number of cases in which 
the bacilli have been found in cases of abscess and 
necrosis of bone, and in periostitis and osteomyelitis, 
at very long periods after the original attack of 
typhoid. The case of Buschke (p. 20), in which 
seven years had elapsed and yet a pure culture 
was found, has already been referred to. The next 
longest cases are those of Bruni and Sultan (p. 21), 
in which a pure culture was obtained after six years. 
A number of similar cases are given in detail on 
pages 21 and 22. 

These instances, showing the accumulation of the 
bacilli in the bones and their persistence for months, 
and even years, after the fever, explain the other- 
wise curious fact that the cases of periostitis, osteo- 
myelitis, necrosis, and abscesses in the bones occur 
at such long periods after the fever and so much 
later than most of the other surgical complications 
and sequels of typhoid. Why in some cases, as in 
those of Quincke, though the bacilli are present, 
they do not produce any of these disorders of the 
bones, we do not know. Probably it is clue to the 

1 Dehu, loc. cit., p. 90. - Arch, de Physiol., 1SS7. 

3 Zieglefs Beitrage, 1895, xy i'> 221 - 



Il8 SURGERY OF TYPHOID FEVER. 

fact that the general health is such that their dele- 
terious tendency and influences are successfully 
vanquished. Possibly, if not probably, most per- 
sons convalescent from typhoid, for a consider- 
able time after the fever have foci of infection 
which never develop disease, and in time disappear 
because of returning health and vi^or. The cases 
alluded to suo-crest, also, the need for care during - 
convalescence and after recovery, lest if the general 
health suffer or an injury be received, the latent 
bacilli may be aroused into a dangerous activity and 
cause disease of the bones. For instance, Mercier x 
relates a case in which six weeks after convales- 
cence the patient fell, striking his fore-arm against a 
piece of wood. This was followed by periostitis and 
abscess of the ulna. As this case occurred before 
the bacillus was known, no bacteriological proof of 
its typhoid origin was obtained. 

These latter cases may be analogous in part to 
a number of instances in which, after a periostitis 
has arisen with all the ordinary signs of inflamma- 
tion, it has subsided, and restoration to health has 
taken place without the formation of pus, the bacilli 
being killed or their toxins neutralized, possibly by 
returning health. 

Still another peculiarity of not a few of these 
typhoid bone cases is that a periostitis will start 
up, reach a certain point, and then subside, it may 
be for months, or even years, and then recur, 
reaching the point where an abscess forms after one 
or two, or it may be even several, such oscillations. 2 

1 Rev. Mensuelle de Med. et de Chir., 1879, iii, 21. 

2 Cf. Parsons, Johns Hopkins Hosp. Reports, vol. v. 



TYPHOID AFFECTIONS OF THE BONES. Iig 

Two other peculiar clinical features of the hone 
cases may be explained by the long-persisting and 
favorable nidus which the bacilli find in the bones. 
Most of the other surgical disorders of typhoid 
manifest themselves in a single place — e.g.<> a mon- 
articular arthritis, gangrene of one leg, etc. While 
occasionally two joints or both legs may be involved, 
yet it is rare. In the bones, however, multiple foci 
of disease are common. Thus, Mercier l reports a 
case in which the left tibia, left scapula, left femur, 
right humerus, and right tibia were all affected re- 
spectively on the seventieth, eighty-eighth, ninety- 
fifth, ninety-seventh, and one hundred and first days 
after convalescence began ; Pean and Cornil, 2 one 
involving the left tibia, and, five months later, two 
places in the other tibia ; Park, 3 one involving all 
the bones of both legs, the pelvis, and the spine ; 
Chantemesse and Widal, 4 one involving the right 
tibia, left femur, a finger on the left hand, and 
the left ulna, at eight weeks, eleven weeks, eight 
weeks, and nearly a year respectively ; Hulin, 5 one 
involving the tibia, the ribs, and the clavicle at the 
tenth week, nineteen months, and about two years 
respectively. Caspersohn 6 reports a case involving 
the left parietal, left tibia, and left ulna, respectively 
during the course of the fever and three and five 
months after the fever, with suppurative parotitis on 

1 Rev. Mens, de Med. et de Chir. , 1879, iii, 21. 

2 Bull. Acad, de Med. Paris, 1891, 3d series, xxv, 599. 

3 Annals of Surgery, 1 89 1, ii, 491. 

4 Bull, et Mem. Soc. Med. des Hop., 1893, 3d series, x, 779. 

5 Contrib. a 1' Etude des Complic. Osseuses de la Fievre Typh., These de 
Paris, 1885. 

6 Festschrift Fr. v. Esmarch, 1893, 455. 



120 SURGERY OF TYPHOID FEVER. 

the forty-eighth day; Catrin, 1 a case in which the 
left tibia, left temporal, and the right tibia (twice) 
were attacked, respectively on the fifty-sixth, sixtieth, 
sixty-fifth, and eighty-third days ; and Flirbringer 2 
reports a case in which there were seven successive 
attacks in the course of four months, involving ten 
different portions of the body, but followed by com- 
plete recovery and disappearance of all evidences 
of disease. In addition to these cases there are a 
large number of cases in our tables in which two 
bones were involved. 

Besides this, it will have been observed that in the 
multiple attacks above referred to the various bones 
are not involved all at the same time, but successively, 
and not seldom after long intervals, sometimes even 
in apparent later health. ( Cf. case of H. W., p. 1 23.) 
So long as the bacilli remain in the bones, so long is 
the patient in danger. He is only safe when they 
are totally eradicated, and as to the date when this 
has happened, we can, apparently, only tell by the 
cessation of the attacks. The following- case illus- 
trates repeated recurrences of periostitis and super- 
ficial necrosis prior to an attack of typhoid, and that 
the fever did not, apparently, cause a renewal of the 
disease in the bone : 

Case VIII. — R. W. P., clergyman, age thirty-one, 
first consulted me November 5, 1877. At nine years 
of age, presumably from exposure to cold, he had 
several attacks of periostitis of the entire left tibia 
and of the left humerus, the latter only in one spot. 
In both of these places this was followed by necrosis. 
He lost several pieces of bone from the tibia at 

1 Gaz. des. Hop., 1896, No. 42. 2 Brit. Med. Jour., 1890, i, 1033. 



TYPJ '/()//) AFFECTIONS OF THE BONES. 121 

various times until he was fifteen years old. At 
twenty-eight he had another attack of periostitis of 
the tibia, followed by suppuration which was entirely 
superficial and was not followed by necrosis. At 
twenty-five he had typhoid fever, during which he lost 
flesh very rapidly, he thinks as much as 30 pounds 
in three days, the cerebral symptoms being- the most 
prominent. He was in bed for a month, but returned 
to his college duties in two months. No periostitis, 
necrosis, or any other trouble occurred in the bones 
after his typhoid fever. About September 1, 1877, 
six years after the fever, two small spots of perios- 
titis appeared again in the middle of the tibia, and at 
present (Nov. 5, 1877) there are two points at which 
the bone is exposed — one y 2 of an inch in diameter, 
the other only a pin's point in size. The bone is 
dry, red, and tender, but is not painful in walking. 
The bone later discharged, since which time he has 
been well. 

Park T has called attention to the rapid growth 
which often follows an attack of typhoid in adoles- 
cents, sometimes as much as a millimeter a day, and 
ascribes it to the typhoid irritation of the osteogenetic 
tissues. The long persistence of the bacilli in the 
bones may readily explain this, especially if they are 
present in such small numbers as to produce only a 
mild irritation but are not numerous enough to cause 
inflammation and suppuration. 

In a few cases the osseous lesions have arisen at 
the seats of old fractures or strumous cicatrices. 
Thus, Routier and Terillon 2 report a case of perios- 
titis of the left ulna and rio-ht tibia at the seat of 
previous fractures in childhood, and Finlayson 3 a 

1 Miitter Lectures on Surg. Pathol., 260. 2 Prog. Med., April 12, 1884. 
3 Amer. Jour. Med. Sci., March, 1891. 



122 SURGERY OF TYPHOID FEVER. 

case of necrosis of both tibiae at the site of old 
strumous lesions marked by a scar. 

Recent injury seems to be the cause which has 
precipitated the osseous lesions in some cases. 
Thus, Mercier 1 and Levesque 2 report three cases in 
which the osseous lesions followed a fall after the 
fever, and Clarke 3 one in which a fall on the knee 
preceded the fever. As the suppurative periostitis 
of the lower end of the femur did not occur until the 
fifth week after defervescence, the relation of the two 
is doubtful. A case reported by Jackson 4 in a man 
of forty-two is, curiously enough, attributed to the 
injury inflicted by the use of the stethoscope. Peri- 
ostitis of the third rib followed five months after the 
beginning of the attack, and when he was in complete 
health he alleged that while in bed he felt soreness 
at that point from the pressure of the stethoscope. 

Colzi's experiments 5 may throw some light upon 
this phase of the disease. The injection of two c.c. of 
a pure culture in a rabbit's ear always gave negative 
results, but if the injection was preceded by a sub- 
cutaneous fracture an abscess resulted in n out of 
14 cases. The well-known development of tubercu- 
lar "abscesses" after injury would reinforce this 
view. 

Witzel 6 has called attention to the — as he believes 
— much greater recent frequency of the bone lesions 
of typhoid, and attributes them to the more frequent 

1 Rev. Mens, de Med. et de Chir., 1879, in > 2I - 

2 De la periostite dans la convalesc. de la Fievrt Typhoide, Paris, 1879. 

3 Jour. Amer. Med. Assoc, April 4, 1891,473. 
1 Brit. Med. Jour., 1885, i, 428. 

5 Jordan, Beitr. klin. Chir., 1893, x. 6 Park's Lect. 



TYPHOID AFFECTIONS OF THE BOXES. 123 

injuries received from the sides and edges oi the 
bath-tub, since this method of treatment has been 
introduced. While this may not be so, yet the cases 
above cited would seem to show that an injury is 
quite capable of precipitating- such troubles in the 
bones, and that great care should be taken that in 
bathing no accidental injury, even a slight one, 
should be received, and also that injury should be 
carefully avoided, even long after recovery. 

Allied to the influence of injury is that of muscular 
strain. To illustrate this, I quote from my earlier 
lecture a case in point, with the history for two years 
later. It illustrates the wide-spread mischief that 
may follow in the osseous system, when put to the 
test by labor, months and even years after such a 
fever. 

Case IX. — H. W., a remarkably stout, healthy lad 
of sixteen, was attacked Dec. 17, 187 1, with typhoid. 
He was delirious for four weeks, was in bed four 
months, and first got out of doors in May, 1872. Bed- 
sores had formed, but were kept in check by inces- 
sant care. In the autumn of 1872, not yet being 
strong, he went to work at riveting in an iron works, 
which required him to stand and use a ten-pound 
hammer, the main strain being naturally on the 
rieht arm and lee. His ricrht arm soon be^an to 
swell, and finally four fistulae formed. After the 
removal or discharge of several pieces of bone, this 
arm recovered in about a vear. Retu miner then 
to the same work, his health being still impaired, his 
ricrht thigfh beean to trouble him, and broke out and 
healed several times, discharging several pieces of 
bone. He came under my care in July, 1875. He 
had then a scar and five open sinuses in the thigh, 
all leading in the direction of the bone, and in one, 



124 SURGERY OF TYPHOID FEVER. 

just above the knee, a fragment of dead bone an 
inch long was found. This sinus and a second just 
below the patella, an offshoot from it, threatened to 
invade the knee-joint. Meanwhile, in the fall of 

1874, though he had not done any work on account 
of his right leg, the left thigh broke out, and a sinus 
in the direction of the bone was established, but no 
dead bone was ever actually found here. In Jan- 
uary, 1875, an abscess also appeared in the left arm, 
and after the discharge of some bone finally healed. 
I enlarged all the existing sinuses in the right thigh, 
removed the dead bone, and, after I had treated the 
case carefully for four months, all the sinuses healed. 
A new one, however, appeared early in 1876 in the 
right thigh, but no dead bone was found. In Febru- 
ary, 1876, it healed, broke out again in July, and did 
not heal until December, after a counter-opening 
had been made. In July, 1879, periostitis again 
manifested itself at the insertion of the internal ham- 
string tendons of the right leg. An incision was 
made down to the bone, giving exit to pus. An- 
other abscess also developed over the sternum at 
the origin of the right pectoralis major. This also 
was opened and the pus evacuated. He had gone 
to work as an engineer meantime. I have not seen 
him since. His health markedly improved early in 

1875, and since my various operations he has grown 
to be exceedingly robust and hearty again. His 
right knee, which was stiff from the sinuses among 
the muscles of the thigh and near the knee-joint, be- 
came as mobile as ever, and he works with ease. 
The abscesses in the two arms were at or near the 
deltoid insertion ; of those in the right leg, the first 
was at the insertion of the gluteus maximus, the last 
at the insertion of the hamstrings, that in the left leg 
near the lesser trochanter, and one at the origin of 
the great pectoral muscle, all points at which muscu- 
lar strain would come in standing and hammering, 
and later in his work as an engineer. 



TYPHOID AFFECTIONS OF THE BONES. 125 

In this case the recurring attacks of periostitis 
leading to abscesses and superficial necrosis covered 
a period of at least eight years, and very possibly 
continued after I lost sight of him. The)' involved 
the right humerus, both femurs, and the sternum in 
eight or ten successive attacks, and were nearly all at 
points of muscular attachment, and, therefore, of 
strain. At the same time, it is to be observed that 
they were all essentially local attacks, the general 
health being good. They may easily be explained 
on the theory that the bacilli being present in the 
bones (the case was observed before the bacillus 
of typhoid was known), a local irritation was caused 
by muscular strain, and the bacilli were re-stimulated 
to the point of abscess formation, and even of 
necrosis. 

On looking over our tables I find that a consider- 
able number of cases would seem to justify the 
inference that muscular strain may have been the 
immediate factor in producing the periostitis or other 
lesion. Of all places in the body to be attacked by 
periostitis, such points as the anterior superior spine 
of the ilium, the tuberosity of the ischium, and the 
ereat trochanter of the femur would be the last to be 
thought of. Indeed, I do not remember myself ever 
to have seen them involved in any case of ordinary 
periostitis or in any case I have seen recorded in 
medical literature. But in our tables I find that 
Sacchi 1 records a case of osteo-periostitis of both 
anterior superior spines of the ilium, of the tuberosity 
of the left ischium, and of the sacral and coccygeal 
regions, the right-sided troubles developing during 

1 Revista Veneta, Jan., 1889. 



126 SURGERY OF TYPHOID FEVER. 

convalescence, the left two months later. Now, all 
of these points are points of attachment of large and 
powerful muscles of the thighs and hips, which would 
be among the first called upon for a relatively severe 
exertion, as with returning health the patient would 
becnn to stand, walk, and work. 

Ebermeier l records another case involving the 
tuber ischii and another of the inner side of the head 
of the tibia (inner hamstrings). Hulin 2 records 
another case of a suppurative periostitis of the left 
great trochanter. 

Turgis 3 attributes an osteo-periostitis of the hu- 
merus eight months after the fever, partly to a blow 
and partly to excessive muscular action. Martha 4 
records a case involving the inner side of the head 
of the tibia and the inner condyle of the femur, the 
tibia being so enlarged at the point of disease as to 
prevent full extension of the knee. The bone dis- 
ease arose two and a half months after the patient 
had eone to work, and the points attacked were 
those of muscular attachment. 

Another case, reported by Verchere, quoted by 
Turgis 5 is curious by reason of the alleged cause, 
and may be an illustration both of traumatism and 
muscular strain. A periostitis of the sternum, in a 
woman of sixty-eight was attributed to pressure 
from cutting bread while holding the loaf against the 
chest. In a lar^e number of other cases there is no 

1 Deutsch. Arch. f. klin. Med., 1889, xliv, 140. 

2 Contrib. a 1* Etude des Complic. Osseuses de la Fievre Typhoide, These 
de Paris, 1885. 

3 Contrib. a 1' Etude de l'Osteo-periostite Conseq. a la Fievre Typhoide, 
These de Paris, 1884. 

4 France Med., April 4, 1888. 5 These de Paris, 1884. 



TYPHOID AFFECTIONS OF THE BONES. 127 

doubt that the periostitis developed at points of 
muscular attachment, but no mention is made of the 
precise point involved; often only "the humerus," 
" the thigh," etc., are mentioned, because the atten- 
tion of the reporter probably had not been called to 
the possible relation between the disease and mus- 
cular strain. The cases described are, however, I 
think, sufficient to establish the probability, if not 
the certainty, of the inference. In the shaft of the 
tibia, however, — the most frequent site, — this reason 
can not be assigned. 

Varieties of Disease of Bone after Typhoid. — 
The two series of cases show a marked contrast 
as to the frequency and infrequency of the various 
forms of osseous lesions reported up to 1876 and 
after that date. 

Series Series 
Disease. of 1876. of 1896. Total. 

Necrosis, 50 35 85 

Caries, 12 1 13 

Periostitis, 3 107 no 

Osteitis (bone abscess,) . — 12 12 

Osteomyelitis, — 10 10 

Granuloma, — 2 2 

Exostosis, — 1 1 

Uncertain, 4 — 4 

69 168 237 

The table is not absolutely accurate. Many of 
the cases may overlap — e. g.,3. periostitis may result 
in caries or an osteomyelitis in a necrosis. Many 
of the terms are used loosely by the reporters, who 
often do not nicely or accurately distinguish be- 
tween caries and necrosis, caries and osteomyelitis, 
or osteomyelitis and periostitis. The importance of 



128 SURGERY OF TYPHOID FEVER. 

osteomyelitis especially has not been recognized by 
the profession at large until of late years, and its 
distinctive symptoms, and even its existence, twenty 
years ago were for the most part unrecognized. In 
fact, in typhoid bone lesions, as in the same lesions 
from other causes, the two essential forms of dis- 
ease of the bone are (i) osteo-periostitis and (2) 
osteomyelitis ; while caries, necrosis, bone abscess, 
etc., according to various circumstances, may result 
from either. But taking the table as it stands, peri- 
ostitis is undoubtedly by far the most frequent form 
of osseous lesion. 

Case X. — The following case, the report of which 
I also owe to the courtesy of Dr. D. S. Rice, of 
Hastings, Pa., who has had an unusually rich experi- 
ence in the surgical results of typhoid fever, is a 
good illustration of typhoid osteomyelitis : 

"Grace D., German, age fifteen, when twelve years 
of age had a severe attack of typhoid, lasting five 
weeks. She then convalesced rapidly, when suddenly, 
in the third week of convalescence, she complained 
of exceedingly severe pain in the middle third of the 
left tibia, without swelling or rise of temperature. A 
week after the pain began the temperature quickly 
rose to 105 , but the leg was only slightly swollen 
and was not discolored. An incision six inches 
long was immediately made, and the bone was tre- 
phined, evacuating three ounces of dark pus. The 
medullary cavity of the bone was then chiseled open 
for six inches, irrigated, and packed with gauze. The 
patient made an uninterrupted recovery, and has 
been well ever since." 

In the ribs especially, I suspect that many of the 
cases classed as periostitis were really instances of 
osteomyelitis. Necrosis is most frequent in the tibia, 



TYPHOID AFFECTIONS OF THE r>0 Mis. 129 

but in the ribs, as Paget 1 lias pointed out, necrosis 
does not occur. On the contrary, it may occur, though 
rarely, in the costal cartilages. Helferich 2 and Berg j 
have especially called attention to the age and loca- 
tion in typhoid ailments of the ribs and costal carti- 
lages. Periostitis, osteomyelitis, and chondritis are . 
the usual forms of disease in the ribs and their car- 
tilages. As the chest wall is thin, operations here 
are apt to be less thoroughly done than elsewhere 
on account of the danger to the pleura, the lungs, or 
the pericardium, or even of opening the pleura or 
pericardium, and hence these cases are peculiarly 
apt to be chronic and to require repeated opera- 
tions. Stephen Paget 4 has related a case of 
periostitis of both tibiae and the lower left costal 
cartilages, which only healed in the latter place after 
four or five operations in two and a half years. The 
following cases are good illustrations, both of the 
character and chronicity of the bone lesions of 
typhoid, in one of which the pleural cavity was 
widely opened without collapse of the lung or other 
disaster : 

Case XL — J. K., age forty-two, of Patton, Cambria 
Co., Pa., was kindly sent to me at the Jefferson 
Medical College Hospital by Dr. D. S. Rice, of 
Hastings, Pa., February 19, 1895. His father died of 
some gastric trouble; his mother of dropsy. Three 
sisters are living, all fairly healthy. No family history 
of tuberculosis or cancer. He was in £ood health 
until eighteen years ago, when he had an attack of 
typhoid fever which confined him to bed for ten weeks. 

1 St. Bart. Hosp. Rep., 1S76. 

2 Berlin, klin. Wochen., Oct. 20, 1 890, 979. 

3 Centralbl. f. Chir., 1896, 153. 4 Surgery of the Chest, 137. 

9 



130 SURGERY OF TYPHOID FEVER. 

Toward the end of this period he had some pain in 
the right sixth and seventh costal cartilages. When 
he got out of bed he discovered a small hard mass 
at the junction of these cartilages and their ribs. 
This gradually increased in size and was finally laid 
open, but no pus escaped. The wound closed, but the 
mass still grew larger and more tender, but without 
discoloration. In July, 1894, Dr. Rice incised the 
tumor and removed part of one rib and a portion of 
the sternum. The operation resulted in a small 
sinus, which never closed. A second operation was 
done in October, 1894. In January, 1895, tne wound 
meantime never having healed, he was operated on 
again at the Pennsylvania Hospital by Dr. Thomas 
George Morton, who also removed a portion of the 
sternum and the parts of some ribs, but the wound 
never healed. 

Status Prcessens. — There are two sinuses, the upper 
one directly over the sternum and on a line with the 
nipple ; the second about two inches below, at the 
right border of the sternum. Three inches from the 
nipple is a point of exquisite tenderness ; all the tis- 
sues are indurated and thickened. His general 
health is good ; he has neither cough nor night- 
sweats and has gained fifteen pounds in weight. 
There is no history of tuberculosis. 

Operation, February 20, 1895. An incision four 
inches lone was made over the sternum down to the 
bone. Two horizontal incisions were then made 
from the ends of the first to the line of the ri^ht 
axilla. The quadrangular flap thus made was dis- 
sected away, disclosing the sternum and ribs. The 
fifth, sixth, and seventh ribs were all found softened 
with osteomyelitis. Between three and four inches 
of each rib were removed as well as a large part of 
the sternum. In removing the fifth rib, in spite of 
the utmost care in loosening the tissues on the in- 
ternal surface, a rent was made in the pleura in the 



TYPHOID AFFECTIONS OF THE BONES. 131 

fifth intercostal space. This was closed by a finger 
while further dissection was being carried on, and 
later was stuffed with some iodoform gauze. In spite 
of this, however, the air was sucked in and out during 
respiration to a considerable amount. When the 
ribs had been finally removed, the gauze was 
removed and the opening inspected. It had then 
gradually been torn to an opening nearly 4 cm. in 
diameter. Through this with each inspiration the 
lung made a moderate hernia, and fell away again 
from the chest wall on expiration ; no collapse of the 
lung occurred. During expiration I attempted to 
draw the edges of the pleura together with a needle 
(the pleura was entirely healthy), but it was so firmly 
attached to the margins of the opening that the 
attempt to tie the stitches simply made the hole 
larger by an additional tear in the pleura. Accord- 
ingly, I again stuffed the opening full of iodoform 
gauze and replaced the flap over it, allowing the end 
of the gauze to protrude at its lower border. His tem- 
perature on the day after the operation rose to 102 , 
fell by the next day to 101 , beyond which it never 
went, but reached the normal on the nth of March, 
nearly three weeks after the operation. There 
was considerable local pain, the result of traumatic 
pleurisy, at the point where the pleura was opened. 
A few days after the operation, however, he was 
able to be out of bed. He was discharged on April 
7, 1895. The wound, which at first had entirely 
closed, had reopened at two points, and there was 
evidently still further disease of the bone. In fact, 
at the time of the operation I was quite doubtful 
whether 1 had removed all of the diseased ribs, but in 
view of the probable pleurisy and of the very exten- 
sive removal of bone which would be required, and 
the possibility of a traumatic pleuro-pneumonia, I 
thought it best at the time to restrict the operation 
as already described. Cultures were made at the 



132 SLRGERY OF TYPHOID FEVER. 

time of operation from the sternum, ribs, and pleura, 
but they failed to develop any growth. 

On December 24, 1895, Dr. Rice reported that the 
patient's general health was very good. The ends of 
the ribs, where they had been excised, were solid, and 
he could stand firm pressure against the chest wall 
without pain. The only discharge then existing was 
over the sternum. 

He returned to the hospital on March 23, 1896, 
when I found a sinus leading down to the sternum, 
with a tumor the size of a pigeon's egg at the bor- 
der of the ribs on the right side. The chest wall, 
where I had excised the ribs, was quite firm. The 
ends of the excised ribs could be felt, but the tissue 
between was filled up with firm fibrous tissue, which 
resisted pressure quite well. No evidence of the 
old pleuro-pneumonia resulting from the first opera- 
tion could be detected. 

Operation, March 25, 1896. A rectangular flap 
was turned up, the middle of which was at the sinus 
leading down to the sternum. An incision was then 
carried from the earlier one alon^ the border of the 
ribs on the right side into the tumor already de- 
scribed. A soft spot was found in the line of the 
nipple on the seventh rib. After chiseling into this, 
I found that the spongy tissue was entirely broken 
down, the bony trabecular gone, and the medullary 
cavity filled with granulation tissue, which tunneled 
under the skin from the soft spot mentioned all the 
way up to the sinus leading to the surface. This I had 
not observed when I was operating on the diseased 
sternum. With the double rongeur forceps I re- 
moved the whole of the anterior wall of this tunnel, 
scraped out the medullary contents with a sharp 
spoon, and then used the Paquelin cautery to de- 
stroy any possible infection which had escaped the 
curette. His recovery was steady, but very slow. 
He went home, however, June 19, 1896, nearly three 



TYPHOID AFFECTIONS OF 77/ E BONES. 133 

months after the operation. Even then there was 
still a small superficial ulcer, from which, however, 
no sinus could be detected leading- down to the 
bone. 

Inoculations from the diseased bones were made 
by Dr. Kyle, and only staphylococci were found to 
be present. 

In December, 1897, Dr. Rice stated that the patient 
is entirely well, and doing light manual labor. 

Case XII — I am indebted to Dr. Rice for the fol- 
lowing additional case of presumed osteomyelitis of 
the ribs after typhoid fever : " A man, age forty, had 
a severe attack of typhoid fever in 1894, from which 
he made a good recovery. Three months after the 
attack a large inflammatory area formed over the 
sternum and ribs, and the ribs on the right side be- 
came so softened that they bent under very little pres- 
sure, and were so flexible that he was obliged to wear 
a bandage in order to ease his breathing. A small 
effusion of clear serum formed at the junction of the 
eighth and ninth ribs with their costal cartilages. 
This was drained aseptically, and under treatment 
with the phosphates the ribs became quite solid. 
But at the middle of the sternum, and at two points 
in the right chest and one on the left, the disease 
has recurred in December, 1897." 

Case XIII — I am indebted to Dr. D. S. Rice 
also for the following case of osteomyelitis of the 
left tibia : " A girl, age thirteen years, suffered from 
an attack of typhoid fever for thirty clays. Two 
weeks after entire recovery she was seized with 
severe pain over the left tibia, four inches above the 
ankle. The temperature rose to 105 and the pain 
was so severe that six days after the onset opera- 
tion was advised. The leg was but little swollen 
and there was no discoloration. The shaft of the 
tibia was exposed by an incision eight inches long 
and trephined. A large quantity of dark pus 



134 SURGERY OF TYPHOID FEVER. 

escaped from the medullary cavity. The bone was 
chiseled out for a distance of six inches. She made 
an excellent recovery and has remained well for 
over a year." 

Case XIV. — H. M. age eighteen, was kindly sent 
to me at the Jefferson Hospital March 19, 1896, by 
Dr. Hollenbeck, of Shamokin, Pa. At twelve years 
of age he suffered from a severe attack of typhoid 
fever, which lasted for ten weeks. While convales- 
cing from the fever two weeks after defervescence, 
the inner surface of the left thigh just above the knee 
became swollen and slightly tender. In April, 1895, 
the swelling was lanced, and in October an opera- 
tion was performed under an anesthetic. Eight 
months after the attack of fever the right ankle en- 
larged and suppurated. It ruptured spontaneously 
a year and a half ago, when fragments of bone 
were discharged and the abscess healed. The dis- 
ease never interfered with his walking. The sinus 
above the knee has discharged continuously since 
the operation of last October, and is still open. 

Operation^ March 31, 1896. An incision was 
made from above the inner condyle of the left femur 
12.5 cm. long, and the sinus traced from the inner 
border of the shaft of the femur some distance up 
the shaft, and also across the posterior surface of 
the shaft in the upper portion of the popliteal 
space. At this point a sequestrum was found 32 
mm. long, triangular in shape, the base being 1 2 
mm. in breadth. The femoral artery was exposed 
at the upper portion of the wound. The granula- 
tion tissue of the sinus was given to Dr. Kyle to 
examine for typhoid bacilli, who reported as follows: 
" No typhoid bacilli were found, but a pure culture 
of staphylococcus pyogenes aureus was obtained." 

The bones seemed to have healed after the 
separation of the sequestrum, as no bare bone was 
discovered. All the granulation tissue was thor- 



TYPHOID AFFECTIONS OF THE BONES. I 35 

oughly removed and the wound packed with iodo- 
form gauze. His temperature only once rose to 
99. 2°. The wound, however, like all typhoid 
wounds, was very sluggish in healing. He went 
home May 21, \8g6, after two months in the hos- 
pital, the wound even then not being; quite closed. 

Necrosis of a lamella of bone lining the wall of 
the medullary cavity — e. g. y of the tibia, or what in 
my Toner Lecture I called "central necrosis," and 
of which I then collected three cases — does not seem 
to have been observed since 1876, except by Klemm, 





Fig. I. — Two foci of osteo-periostitis (A and B) following typhoid fever- 
" Shirt-stud Abscess " [boitton de chemise). 



in a man of thirty-nine, whose left femur showed a 
sequestrum, 2 X 1 cm., lying in the pus. Very pos- 
sibly this may be due to faulty observation, for I 
suspect it occurs, though only very occasionally. 
Colzi 2 has observed it also in one experimental 
case after five weeks of suppuration. 

A not infrequent form of bone abscess which, if 
not understood, may be very imperfectly and in- 
completely treated, is that to which Chantemesse 

1 Arch. f. klin. Chir., 1893, xlvi, 8S5. 

2 Jordan, Beitrage klin. Chir., 1893, x. 



136 SURGERY OF TYPHOID FEVER. 

has given the happy description " bouton de chemise'' 
or " shirt-stud abscess." Cornil and Pean * give a 
very good illustration of this form of abscess, which, 
with their kind permission, I have reproduced (Fig. 
1). In this form there is a localized abscess out- 
side the tibia, probably under the periosteum, and 
another similar one under the outer layer of the 
bone or even in the medullary cavity, the two 
abscesses being connected by a cloaca or sinus 
through the wall of the bone — the shank of the 
"button." To treat only the external abscess will 
be fruitless. The bone must be trephined or chiseled 
into and the second abscess thoroughly evacuated, 
and its walls chiseled away if we wish a cure. 

Sex. — As in the other surgical typhoid disorders, 
males largely preponderate, counting, in the two 
series : 

Males, 123 

Females, 63 

Total, 186 

Age. — Park 2 is in error when he says that two- 
thirds of the osseous lesions of typhoid occur in 
children and adolescents. This is true of even a 
much greater percentage in the joints (p. 102), but 
my tables show that in the bones there were under 
twenty, 56; from twenty to thirty, 71; from thirty to 
forty, 23 ; over forty, 16. Total, 166. 

Taking thirty, however, as a dividing line, there 
were 127 cases thirty years of age and under, and 
39 cases over thirty. 

1 Bull. Acad, de Med., 1891, xxv, 602. 2 Mutter Lectures, 260. 



TYPHOID AFFECTIONS OF THE BONES. I 3/ 

So far as I have observed, there is only one part 
of the body in which osseous disease occurs almost 
uniformly later in life — the ribs and costal cartilages. 
The table shows that not a single case of disease of 
the ribs or their cartilages occurred before twenty. 
Of 32 cases, the age is given in 18: 5 were from 
twenty to thirty, 6 from thirty to forty, 7 over forty ; 
that is, there were 13 over thirty — 7 of whom were 
even over forty — to 5 under thirty. 

Helferich, * who has observed eight cases, has 
called attention to the fact of the late appearance 
of disease in the ribs. Most of these probably 
should be added to the cases over thirty (for as the 
age is not given they could not be tabulated), and 
this would markedly increase the disproportion. He 
attributes it to the changes which occur, at least 
in the cartilages, in later life, an explanation which 
seems reasonable. It is noteworthy, also, that when 
disease attacks the ribs it quite as frequently attacks 
two or three or even four as a single rib. 

Paget 2 twenty years ago noted, as has also Helfe- 
rich, that, in sharp contradistinction to tubercular 
disease of the ribs, typhoid periostitis and osteomye- 
litis do not depress the general health. Indeed, in 
most of the bone cases this is true. The disease 
seems to be almost purely local. This naturally 
raises the question whether this may not be due to 
an acquired " immunity" of the system at large as a 
consequence of the fever. This seems at least a 
probable explanation of the undoubted fact that all 
of the lesions which occur during or after convales- 
cence from typhoid cause the patients to suffer almost 

1 Berlin, klin. Wochen., 1890, 979. 2 St. Bart. Hosp. Rep., 1876. 



133 SURGERY OF TYPHOID FEVER. 

wholly locally and to manifest but little febrile reac- 
tion. 

Locality. — I have gone over the cases in the 
table and tabulated the various regions involved. 
Where more than one bone was attacked, each bone 
has been entered upon the list, and I find the results 
as follows : 

Skull, i 

Mastoid, 3 

Frontal, 1 

Parietal, 2 

Superior maxillary, 5 

Inferior maxillary, 2 

Head, total, 14 

Sternum, 3 

Ribs, 40 

Vertebrae, 6 

Trunk, total, 49 

Clavicle, 5 

Scapula, 2 

Humerus, 11 

Forearms, 2 

Radius, 2 

Ulna, 15 

Hands, 4 

Upper extremity, total, 41 

Pelvis, 8 

Femur, 22 

Tibia, 91 

Fibula, 3 

Foot, 8 

Lower extremity, total, 112 

Total number of bones attacked, . . . . 216 

The first thing that strikes one upon comparing the 
distribution of disease of the bones in the different 



TYPHOID AFFECTIONS OF THE BONES. 139 

parts of the body is, as is noted in the chapters on 
the Joints, Gangrene, etc., the extraordinary fre- 
quency of bone disease in the lower extremities, — 1 1 2 
as against 104 in all other parts of the body, — this, 
also, in spite of the fact that the part of the tibia most 
often involved — the antero-internal part of the shaft 
— has no muscles attached to it. This may be partly 
accounted for by slight accidental injuries, a possibility 
which can hardly be invoked in case of the femur 
except at the condyles. But as insisted upon in the 
chapter on Gangrene, I believe it is to be ascribed to 
the legs, as legs ; i. e., as the most distant part of the 
peripheral circulation, where nutrition is most slug- 
gish and its activities most easily disturbed and im- 
paired. That, as Parsons T has remarked, the foot, 
as well as the hand, is less often involved than most 
other parts of the body is to be ascribed, I think, 
largely to the more active circulation in bones, many 
of them at least made up largely of spongy tissue. 

Taking the superficial bones — those of the head, 
sternum, clavicle, ulna, tibia, ribs, hands, and feet 
— as contrasted with the deep, — the vertebrae, scap- 
ula, humerus, radius, pelvis, femurs, — the relative 
number is as 180 to 51. Whether this has any sig- 
nificance in relation to the possible influence of acci- 
dent is a question. 

Date of Onset. — The facts here are both signifi- 
cant and instructive. 

Of 186 cases, there arose : 

In the first two weeks, 16 

From the third to the sixth week, 66 

From months to years after the fever, . . .104 

1 He only found one case in the feet. 



140 SURGERY OF TYPHOID FEVER. 

Bone disease is, therefore, rarely a complication 
of typhoid, but is, in the vast majority of cases, a 
sequel. It rarely arises during the course of the 
fever (the earliest case 1 arose on the tenth day), 
but almost always in convalescence, and, in fact, in 
over one-half the cases after convalescence was well 
established. It is at this time that muscular strain be- 
gins by the patient's commencing to stand and walk, 
and later by his return to ordinary manual labor ; it 
is then that blows and other usual slight accidents 
may occur ; it is then that the slow changes in the 
bones begin to show themselves; it is then that the 
bacilli, driven, so to speak, from other parts of the 
system, take refuge in the bones, and lie in wait, 
ready to avail themselves of any unfavorable con- 
ditions of fluctuating health or varying circulation, 
or of anything causing a locus minoris resistentice. 

The experiments of Dmochowski and Janowski 2 
are exactly in point. If the bacilli were injected 
under the sound skin of an animal no suppuration 
occurred, but if the tissue had been weakened by 
inflammation, by scars, or by local bleedings, then 
suppuration followed, or in some cases the animals 
died before any local changes could manifest them- 
selves. In all pathologically-altered tissues suppu- 
rative action was apt to follow. 

The inferences from these facts are plain. The 
subsidence of the fever, and even the establishment 
of full convalescence, do not justify the physician in 
relaxing his vigilance. No patient recovered from 
typhoid fever should be allowed to resume the ordi- 
nary activities of life except very gradually, and 

1 Ebermeier, Deutsch. Arch. f. klin. Med., 1889, xliv, 140. 2 Loc. cit. 



TYPHOID AFFECTIONS OF Till-: BONES. 141 

should be cautioned as to oxen slight accidents and 
warned against any severe physical exertion for 
several months after he has apparently recovered. 
At the very first sign of trouble he should return to 
his physician for careful examination and advice. 

Symptoms. — These will vary somewhat accord- 
ing to the type of disease, but only within rather 
narrow limits. The constitutional symptoms are 
rarely very pronounced, and fever especially is most 
commonly absent. In fact, so pronounced is this in 
the true typical typhoid cases, as distinguished from 
those arising from a pyogenic or a mixed infection, 
that Chantemesse and Widal l call this type of ab- 
scess " cold abscess," though it has, of course, no 
relation to the tubercular abscesses commonly de- 
scribed by this name. A possible explanation of 
this peculiarity of post-typhoid lesions has been ad- 
vanced on the preceding page. 

The cases may all be classed as either acute or 
chronic. Even in the acute cases, fever, anorexia, 
dry tongue, and constipation may be absent, the local 
symptoms predominating. Occasionally, however, 
in an otherwise chronic case, a temporary exacerba- 
tion may be attended with moderate constitutional 
symptoms. 

Usually the first symptoms will be local pain, ten- 
derness, and swelling, the latter being much more 
extensive than the bone disease which is its cause. 
In not a few cases resolution will follow after a rela- 
tively slow subsidence of the disease. But if, in a 
few days, or more likely a week or two, recovery 

1 Bull, et Mem. Soc. Med. des Hop., 1893, x, 779. 



142 SURGERY OF TYPHOID FEVER. 

does not follow, the parts will become red and then, 
or soon after, may fluctuate. 

In other cases, after an apparent subsidence of 
the disease, and even after weeks and occasionally 
months of supposed health, the pain and swelling 
will reappear at the same spot, and then go on to an 
abscess. Sometimes more than one such oscillation 
or recrudescence will take place, finally resulting 
either in suppuration or a permanent cure. 

For some excellent examples of such oscillating 
cases see Osier and Parsons. 1 Routier and Terril- 
lon 2 record a case in which the tibia was attacked in 
the ninth week during convalescence ; the attack 
subsided, but was followed after some months by a 
relapse and an abscess, which was opened and the 
bone scraped. Two subsequent relapses and opera- 
tions were required to effect a cure. Chantemesse 
and Widal 3 report a case illustrating both the multi- 
plicity and the recrudescence of the bone lesions. 
Lockwood 4 reports a similar case of disappearance 
and reappearance of the swelling in an abscess. On 
pages 20 and 1 18 I have given some other instances 
of a similar character illustrating this curious ten- 
dency to the swinging of the pendulum between 
apparent health and renewed disease, and the case 
of H. W. (p. 123) is not dissimilar. 

Treatment. — Fortunately, surgical treatment in 
most cases is needed, not during the typhoid attack, 
but after return to health. When fluctuation can be 
perceived, unquestionably immediate operation should 

1 Johns Hopkins IIosp. Reports, vol. v. 2 Prog. Med., April 12, 1884. 

3 Bull. Soc. Med. des Hop., 1893, 3d series, x, 779. 

4 Lancet, 1895, i, 535. 



TYPHOID AFFECTIONS OF THE BONES. 143 

be done. It is better, however, to operate even 
before fluctuation arises unless spontaneous resolu- 
tion is fairly certain to follow. By such earl)- inter- 
ference suppuration may be avoided and the case 
cut short. If pus is found, then the cavity must be 
thoroughly treated. The bacilli are more often found 
in the tissues forming the wall of the abscess cavity 
than in the pus. Hence, if the abscess exists only 
in the periosteum and soft parts, these must be 
entirely excised and the bone be chiseled away. If, 
as not seldom happens, the medullary cavity is in- 
volved, then the bone must be widely chiseled away 
so as to expose and remove all the diseased osseous 
tissue. For want of thoroughness, repeated opera- 
tions may be needed, the earlier attempts not having 
entirely removed the disease. Sometimes, although 
no pus is found, extensive operations are required be- 
fore definite healing takes place. Thus, Chantemesse ' 
relates a case in which for osteomyelitis the tibia was 
three times trephined. No pus was found, but the 
disease persisted, and the patient was only cured, a 
year later, by opening the tibia by an extensive 
operation forming a long gutter in the bone. Even 
then no pus was found. 

In no region are these remarks more true than as 
to the ribs and sternum. From their very situation 
and their important relations to the pleura, pericar- 
dium, and lungs, incomplete, and therefore insuf- 
ficient operations are apt to be done, and conse- 
quently have to be repeated. As a rule, the ribs 
must be resected in their entire thickness, and not 
merely partly gouged away. Sometimes it may be 

1 Bull, et Mem. Soc. Med. des Hop., 3d series, vii, 1S90, 655. 



144 SURGERY OF TYPHOID FEVER. 

difficult to say just where the disease stops (cf. Case 
XI, p. 129). The same rule applies to the sternum. 
If the pleural cavity is widely opened, as in my 
case just referred to, little or no mischief may be 
done, even in a suppurative case, provided the sur- 
geon uses rigid antisepsis. 

The form of abscess already described as " bou- 
ton de chemise'' or as I would prefer as perhaps 
more accurate, "dumb-bell" in shape, must not be 
forgotten, and the inner as well as the outer abscess 
be treated as above directed. 

The occurrence of this form of abscess again sug- 
gests the probably more frequent occurrence of " cen- 
tral necrosis " than is mentioned in the recorded 
cases. The sequestrum being small and bone chips 
from the chiseling being present may account for its 
not having been observed. Only those who know of 
its possibility would probably be on the lookout for 
it. Probably Parsons' Case III' was an example in 
point. 

Incomplete operations or neglected disease lead 
to sinuses, which may persist for years. In Sultan's 
case this had extended to six years, and yet no pyo- 
genic infection of the sinus had occurred, a pure 
culture of the typhoid bacilli being found. 

In Anger's case 1 the sinus continued for ten years, 
and only healed after the removal of a sequestrum. 

The tendency to chronicity, to persistent sinuses, 
and especially to recurrences, are among the most 
marked characteristics of the bone disorders following 
typhoid. Occasionally the disease of the bone may 

1 Turgis, Contrib. a l'Etude de l'Osteoperiostite Conseq. da la Fievre Ty- 
pho'ide, These de Paris, 1884. 



TYPHOID AFFECTIONS OF THE BONES. 145 

cause extensive disease in the soft parts ; or may ex- 
tend to a neighboring joint, though either complica- 
tion is rare. Amputation in the latter case becomes 
imperative. Only four such amputations occurred in 
the cases reported in the first series ; two died, one 
recovered, and one was under treatment. In the 
second series no case came to amputation. 

The prognosis is almost always favorable. Of 
the 168 cases in the second series, only 11 died; 
recovery followed in 122 cases, the result not being 
given in 35. Of all the 1 1 fatal cases, not one 
can be said to be a pure case of typical bone dis- 
ease from typhoid. Every one suggests either a 
pyogenic or a mixed infection. In only two were 
bacteriological examinations made. In Klemm's J 
case the colon bacillus, as well as that of typhoid, was 
present ; the periosteum was destroyed and the bone- 
marrow red and hemorrhagic. Half a liter of fluid 
was found. In Dunin's 2 case there was also a paro- 
tid abscess, and a mixed infection with the staphylo- 
coccus aureus was found. In another, 3 a mixed in- 
fection certainly occurred, as the patient had also 
erysipelas. In three, 4 the jaws were attacked and 
the tissues of the cheek became eanorenous. In the 
first there was also suppurative parotitis. These were 
quite surely mixed infections. Three others were 
probably cases of septicemia, 5 combined, in the first, 

1 Arch. f. klin. Chir., xlviii, Heft 4. 

2 Deutsch. Arch. f. klin. Med., 1886, xxxix, 369. 

3 Armieux, Rev. Med. de Toulouse, 1875, ix, 42. 

4 Franklin, Lancet, 1879, i, 553; Lawton, Ibid., p. 6S5 ; Alexander, 
Breslauer aerzt. Zeilschr., 1887, No. 23, 271. 

5 Merrier, Rev. Mens, de Med. et de Chir., 1879, iii, 21 ; Rondu, quoted 
by Witzel ; Robin, Gaz. Med. de Paris, 1881, No. 4, 559. 

10 



146 SURGERY OF TYPHOID FEVER. 

with diffused violent phlegmonous periostitis of the left 
femur and ij£ liters of pus. The other two have al- 
ready been referred to (p. 92) under diseases of the 
joints, as both bones and joints were involved. In a 
case of Furbinger's, 1 there was hemato-pyo-pneumo- 
thorax from perforation of a necrotic pulmonary 
focus. In the eleventh case, 2 the patient died from 
erosion of the popliteal vessels after operation on a 
femoral periostitis which had persisted for four years. 
These complicated cases show that in purely 
typhoid cases a fatal issue can be practically ex- 
cluded. Recovery is assured, but is apt to be slow. 

1 Verhandl. Neunte Kongress inner. Med., 1890, p. 207. 
2 Terrillon, Prog. Med., 1884, 285. 



CHAPTER VI. 
TYPHOID ABSCESSES. 

Onk of the most frequent accompaniments of 
typhoid fever are small abscesses in the skin, or furun- 
cles. So far as I know, their bacteriology has not 
been investigated, but the probability is that they 
would be found to contain only pyogenic bacteria. 

Other abscesses arise from various causes. For 
instance, in the abdominal wall they may arise from 
muscular degeneration in the recti muscles (see 
Hematomata); or, again, they may arise by invasion 
from the intestine at a point of adhesion and possi- 
ble perforation ; e. g., in Vance's 1 case, which arose 
in the seventh week, there was an abscess which 
opened at the umbilicus and was found to extend 
from the ribs to the ilium and posteriorly to the 
loin. Possibly they may arise independently of 
either, by the lodgment of the typhoid bacillus in the 
connective tissues, as in the case of Raymond. 2 In 
this case an abscess was found in the abdominal wall 
extending from the umbilicus to the mons Veneris, 
and the sole bacterium found was the bacillus of 
Eberth. In the loose connective tissue elsewhere we 
may have the same phenomenon. For example, in 
Harrison's 3 case, in which there were three relapses, 
a cellulitis of the neck developed two and a half 
months after the third relapse and in the seventh 

1 Med. and Surg. Reporter, 1893, 281. 

2 Pein, loc. cit., p. 58. 3 Lancet, 1S91, i, 1207. 

147 



1 4§ SURGERY OR TYPHOID FEVER. 

month after the beginning of the fever, and extended 
even to the apex of the lung, but did not go on to sup- 
puration. Fraenzel x records a fatal case of mediastin- 
als in a man of fifty-two. Werner 2 also reports a 
case in which several sternal ulcers existing prior to 
the fever extended and perforated into the anterior 
mediastinum. The patient died from profuse hem- 
orrhage, the cause of which was not ascertained even 
by a necropsy. Brieger 3 reports cases of abscesses 
in both axillae, the post-anal region, and the thigh. In 
another case, reported by Daly, 4 an abscess devel- 
oped to the left of the trachea an inch above the 
clavicle. In another 5 there were abscesses about 
the larynx and trachea, but the case was septic. In 
another, reported by Tuthill, 6 an abscess developed 
under the deltoid in which the Eberth bacillus was 
found in pure culture. In another, by Hanquet, 7 
there was an abscess in the left axilla along with 
thrombosis of the right femoral vein, periostitis of 
the left femur, and necrosis of the right ulna. The 
following unreported cases have been seen by 
myself or by friends : 

Case XV. — Mr. S., Haverford College, Pa., age 
thirty-four, has a scrofulous family history, with possi- 
ble inherited syphilis, as indicated by necrosis of the 
turbinated bones. He is of a nervous temperament, 
an excessive smoker, habits good. He was first seen, 

1 Berlin, klin. Wochen., 1874, 97. 

2 Med. Correspondenzbl. Wiirttemb. aerzt. Verein, 1859, xxix, 70 

3 Zeitschr. f. klin. Med., 1886, xi, 263. 

4 Med. and Surg. Reporter, 1882, 346. 

5 Robin, Gaz. Med. de Paris, 1881, 559. 

6 Trans. Med. Soc. State of New York, 1895, 222. 

7 Arch. Med. Beiges, 1892, 305. 



TYPHOID ABSCESSES. 149 

in consultation with Dr. G. E. Abbot, October 19, 
1890. Without prior illness, and following severe 
mental strain and unusual physical exercise and 
exposure to wet, he was taken with three heavy 
chills, September 19, 1890. This ushered in a severe 
attack of typhoid fever. For five days his tempera- 
ture ranged from 105 to 106 , though the pulse 
only once rose above 100. The maximum daily 
movements of the bowels was nine. There was 
no hemorrhage from the bowels, but he suffered 
three hemorrhages from the nose at the end of the 
second week. He was delirious for two nights, had 
considerable frontal headache, but neither temporal 
nor cervical pain. After the decline of the fever 
his recovery was rapid, and by October 15th he was 
out driving. On October 8th, the twentieth day after 
the beginning of the fever, he complained of sore- 
ness at the angle of the jaw on the left side. This 
was followed by moderate swelling and slight red- 
ness, which, however, were stationary. On October 
1 6th, while driving, an accident occurred which 
caused him much excitement and fatigue but no 
physical injury. On the 17th the swelling had 
markedly extended. There was some trouble in 
swallowing and the voice was slightly hoarse. When 
I first saw him I found a very tense condition of 
the tissues of the neck from the ear to the level of 
the cricoid. There was only moderate tenderness, 
and at no point was it clear that an abscess was 
tending to point, though such an abscess, of course, 
was immediately suspected. His general condition 
was good, strength and appetite satisfactory, pain 
not severe, and though it lessened his sleep, it did 
not entirely prevent it. The progress of the case 
was slow. At the end of a week there was some 
edema below the angle of the jaw, the voice and 
deglutition were a little more affected, and there 
seemed to be every reason to suppose that sup- 



150 SURGERY OE TYPHOID FEVER. 

puration was taking place, in spite of the fact that 
he had not had any more pain and there was no 
fluctuation. 

Operation, October 26, 1890. On that morning a 
small amount of pus escaped through the external 
meatus. The abscess was reached at a depth of 4 
cm. of tense edematous tissue under the deep fascia, 
and four ounces of pus were evacuated. The ab- 
scess skirted the larynx and pharynx. In a week 
he was entirely well. I regret very much to add 
that no bacteriological examination was made. 

Case XVL—6r. D. S. Rice, of Hastings, Pa., 
sends me the notes of the following similar case of 
abscess of the neck : 

" Mrs. R., age twenty-three, contracted a severe 
attack of typhoid fever in the early part of October, 
1 897. On the sixteenth day she had a severe hemor- 
rhage from the bowels, when her temperature fell to 
94 , but afterward rose to 105.5 . By the thirty-fifth 
day the temperature had fallen to the normal. A 
week later she had a chill and a rapidly developing 
deep abscess on the left side of the neck. In one 
week there was fluctuation. An incision evacuated 
half a pint of dark turbid pus. The abscess had 
extended under the trachea. She made a good re- 
covery." 

Occasionally these abscesses are multiple, as in 
Quaife's case, 1 in which they were situated over the 
tendon of the biceps, in the left thigh, over the ten- 
don of the left peroneus tertius, over the left scapula, 
and in the substance of the left soleus. In Dunn's 
case 2 they arose at various points over the body, 
arms, and legs. In another, 3 there were abscesses 

1 Australas. Med. Gaz. , Aug., 1885, 271. 

2 Univ. Med. Mag., Sept., 1895, 909. 

8 Laveran, Bull. Soc. Med. des Mop., 3d series, v, 90. 



TYPHOID ABSCESSES, I 5 I 

on the dorsum of the right hand, in the right arm, 
and the left fore-arm, with muscular degeneration in 
the recti abdominis, but no suppuration in the latter 
place. In the abscess only the staphylococcus aureus 
was found, although the typhoid bacilli were found 
in large numbers in the spleen. 

In a number of cases, in such regions as the 
buttock and the thigh, it is often impossible to de- 
termine whether the abscesses arose from direct 
infection of the typhoid bacillus or from muscular 
degeneration followed by rupture and hemorrhages 
in the rectus abdominis ; and whether they owed 
their origin to the pyogenic or to the typhoid micro- 
organisms was only occasionally determined by a 
bacteriological examination. In a few cases, how- 
ever, we can reach definite conclusions on these 
points. Thus, an abscess in the muscles of the 
thigh J showed a pure culture of the Eberth bacillus. 
In a gluteal abscess, 2 also, a pure culture was ob- 
tained. The abscess in Hirsh's case 3 probably was 
secondary to arthritis of the hip-joint, which was 
followed by dislocation. 

In Senter's case 4 — a case of abscess in the muscles 
of the thigh — thrombosis of the pulmonary artery 
caused sudden death. It may readily have been a 
direct result of the abscess. 

There are three cases 5 of perinephric abscess re- 
corded, but in none was a bacteriological examina- 
tion made. As all arose during convalescence, it is 

1 Tinctine, Arch. Med. Exp. et d'Anat. Pathol., 1894, vi, I. 

2 Tinctine, loc. cit. 3 Annals of Surgery, 1S96, 212. 

4 Des Absces muse. dans, la Fievre Typhoide, These de Paris, 18S0. 

5 Alrich, Univ. Med. Mag., Feb., 1890 ; Pearson, Brit. Med. Jour., 1S9I, 
i, 861 ; Adam, Australas. Med. Jour., 1S87, ix, 182. 



152 SURGERY OF TYPHOID FEVER. 

not improbable that they were due to a true typhoid 
infection. 1 

One lumbar abscess* seems clearly to have been 
connected with an old psoas abscess, and was 

1 The two following cases, one of a perinephric abscess originating in a renal 
abscess, and the other of renal abscess and meningitis, were published after the 
tables were completed. They are so important and interesting that I append 
resumes of both from the Bull, et Mem. Soc. Med. des Hop., 1897, No. 2. 
Their typhoid origin was conclusively shown by cultures. 

Fernet and Papillon record the case of a man who entered the hospital on the 
sixth day of the fever. On the thirteenth day he complained of pain in the left 
flank at the level of the enlarged and tender spleen. By the twenty-first day the 
temperature had fallen nearly to the normal, yet his general condition was 
worse. In the lumbar region was a tumor, rounded, elastic, dull on percus- 
sion, in front of the spleen, yet reaching to the lumbar region. On the twenty- 
fifth day Tuffier operated, evacuating a liter of pus. The transverse colon 
had to be displaced to reach the tumor. By the thirty-second day peritonitis 
developed, and he died a week later. The necropsy showed that the abscess 
had begun in the renal tissue, had dilated the pelvis of the kidney, and, rup- 
turing, had produced also a perinephric abscess. Other renal abscesses were 
present. 

Cultures from the pus evacuated at the operation and from the pus of the 
renal abscesses showed pure cultures of the typhoid bacillus ; cultures from the 
dressings some days after the operation and from the renal pelvis at the 
necropsy showed the colon bacillus and saprophytes. Evidently, there had 
been a prior intermittent hydronephrosis, as shown by a marked kink in the 
ureter. The typhoid infection readily seized upon such a weakened organ, 
and all the rest is clear. 

[Not only is this case interesting from the pathological and clinical side, 
but it teaches the lesson that if any abnormal condition, such as movable kid- 
ney, exist, it should be remedied at once, in order not only to cure the existing 
malady, but to avoid later indirect dangers which may easily follow.] 

Troisier and Sicard report a case of renal abscess and meningitis of typhoid 
origin as follows : A man entered the hospital about the fifteenth day without 
characteristic symptoms of typhoid. He was suffering from lead palsy and 
the nervous symptoms of saturnism, including headache. The urine was 
markedly albuminous. Five serum-tests responded positively. Four days 
before death symptoms of meningitis appeared. He died on the thirty-second 
day. The intestine showed typical typhoid lesions, the spleen was diffluent. 
At the base of the brain in a yellowish fibrino-purulent exudate, and, also, in 
an abscess of the kidney, the bacillus of Eberth was found in pure culture. No 
symptoms attributable to the renal abscess, other than the albuminuria, are 
mentioned. 

2 De Lannoy, Phila. Med. Times, July 15, 1882, 707. 



TYPHOID 'ABSCESSES. M 



3 5 



probably only lighted up afresh by the typhoid 
attack. 

The following- case of typhoid during an absolutely 
latent Pott's disease is of the greatest interest, both 
from the perhaps excusable error in diagnosis, owing 
to the peculiarly misleading history and symptoms, 
and as illustrating the value of a bacteriological 
and microscopical examination, without which a 
finally correct diagnosis would not have been made : 

Case XVII. — George W., age twenty-seven, 
entered the Jefferson Hospital August 27, 1897, 
under the care of Dr. J. A. Salinger, on the fifth 
day of an attack of typhoid fever. Typical tdcJies 
rouges appeared on the next day. By the sixth day 
the temperature was normal. A slight relapse, with 
a second crop of spots, occurred from the thirteenth 
to the seventeenth day. He left the hospital Septem- 
ber 2 2d. He re-entered my surgical ward on the 
1st of November. He stated that for two weeks after 
leaving he took moderate exercise, ate heartily, and 
felt very well. Early in October some sharp pains 
were felt in the right groin at intervals for a week, and 
then ceased. They seemed to follow short walks. 
The pain extended into the thigh, and was especially 
noticeable on risine from the sitting to the standing 
posture. On October 10th he first noticed a pain- 
less tumor in the ri^ht Qroin. On his re-admission, 
November 1st, there was a soft oval tumor, 6 by 4.5 
cm., just above Poupart's ligament on the right side, 
and just to the right of the internal ring. The tumor 
was globular, and showed distinct impulse on cough- 
ing to touch and to sight. When he lay down it dimin- 
ished and almost disappeared. It could be reduced, 
and then two fingers could be inserted into an oval 
aperture in the belly wall which exactly resembled 
a hernial rino-. There was no discoloration of the 



154 SURGERY OF TYPHOID FEVER. 

skin. Manipulation of the tumor was not painful. 
The temperature did not exceed 99 . My impres- 
sion was that it was a hernia. 

Lookincr back on it, I think I ouoht to have been 
put on the right track by considering: First, that 
no known case of hernia attributable to the fever is 
on record, so far as I know. Secondly, abscesses 
are quite common. Third, had it been a hernia, it 
was too soft for omentum and also lacked the doughi- 
ness of such a tumor. If bowel, it should have been 
tympanitic, but it was distinctly dull. When reduced, 
also, no gurgling occurred, but this I attributed to 
the apparently wide open ring. I think I should also 
have been put on my guard somewhat by the fact that 
it was not precisely in the position of the internal 
ring, and, in addition to that, one does not usually 
feel the internal rino- as distinctly as this was felt. 

My impression was that the hyaline degeneration 
of the muscles of the belly wall, so constantly seen 
in typhoid fever, had been followed by a rupture of 
the muscular fibers, and this had led to the hernia. 
If this were the origin of the hernia, I deemed it 
wise to wait until distinct regeneration of the mus- 
cular fibers had occurred, which would mve Greater 
assurance of a cure. After a week in bed, however, 
as the tumor was increasing in size, I thought best 
to proceed at once to operate. 

Operation, November 10, 1897. An incision par- 
allel with Poupart's ligament very quickly opened an 
abscess. Not less than a pint and a half of pus 
was evacuated. The pus was not fetid, nor did it 
have any fecal odor. A probe passed upward 15 
cm. — almost to the level of the umbilicus. It also 
passed downward toward the true pelvis, but did not 
reach it. The finger introduced into the cavity dis- 
covered nothing except the ring above described 
and a very large cavity beyond. I curetted away 
considerable eranulation tissue from the walls of the 
cavity, flushed with a hot saline solution, and drained 



TYPHOID ABSCESSES. I 5 5 

with a rubber tube and a small amount of iodoform 
eauze. 

The scrapings and a culture from the pus were 
given to Prof. Coplin for bacteriological examination. 

My impression now was that instead of a hernia 
we had to deal with a typhoid abscess arising in 
the connective tissue between the iliacus internus 
muscle and the iliac fascia. One other possibility 
occurred to me : that it might have arisen from a 
perforation of the appendix by a typhoid ulcer, and 
that this had been followed by an abscess with 
a quiet afebrile course, as one sees not uncom- 
monly after typhoid fever. I asked Prof. Coplin, of 
course, to make a very careful test to determine the 
presence or absence of the typhoid bacillus. After 
four weeks no growth occurred in the culture. In 
the scrapings from the abscess cavity, tubercle bacilli 
but no other organisms were found. I received 
the preliminary report at the end of a week, and 
this at once suggested to me that it was possibly a 
case of Pott's disease, followed by a psoas abscess. 
In conjunction with Prof. H. Augustus Wilson, I ex- 
amined the man's back with the greatest care. Up 
to that time he was not aware that he had ever had 
any trouble whatever with his back. He had never 
suffered any pain, and had it not been for the micro- 
scopical demonstration of the cause of the abscess, 
I would never have suspected that it arose from 
vertebral caries. A very careful examination, how- 
ever, showed unquestionably that he had a Pott's 
disease at the dorso-lumbar junction, and I placed 
him under Prof. Wilson's care. 

All of the symptoms were now perfectly explicable. 
From the surgical point of view they are of no little 
interest, as one might easily be deceived, as I was ; 
and from the pathological side it is also of interest, as 
it showed that a man who has had Pott's disease for 
a period of time long enough to produce a psoas 
abscess containing a pint and a half of tubercu- 



156 SURGERY OF TYPHOID FEVER. 

lar " pus," and to travel from the spine down to the 
level of Poupart's ligament, can pass through an 
attack of typhoid fever and a relapse without having 
any infection in the abscess or the bones from the 
typhoid bacillus ; without aggravating the Pott's 
disease in the slightest degree ; and, indeed, without 
the patient's ever knowing that he had any disease 
whatever in the spine. 

In the abdominal cavity abscesses may arise from 
several causes, and in any particular case it may be 
often difficult and not seldom impossible to deter- 
mine definitely the cause. 

They may arise as localized abscesses from per- 
foration when the adjacent coils of intestine become 
adherent by a protective peritonitis and thus form 
a localized abscess. Eisner 1 and many others report 
such cases. They resemble the familiar form of 
an appendicular abscess, in which the coils of in- 
testine become agglutinated with a similar re- 
suit. In fact, both the appendix, as in non-typhoid 
cases, and the cecum in typhoid, may be perforated 
when no such adhesions exist, 2 and thus require 
operative measures (see Chapter XV, on Perfora- 
tion) ; or, in other cases, perforation and adhesions 
may only be suspected and can not be proved. 

Thus, in one case, 3 after a protracted course and a 
severe relapse an " ileocecal abscess" formed, and the 
pus had a fecal odor. In another, 4 a man of thirty- 
eight is said to have had a " perityphlitis " on the 

1 Trans. Med. Soc. State of N. Y., 1892, 314. 

2 For perforation of the appendix, see Bontecou, Jour. Amer. Med. 
Assoc, 1888, i, 106; Alexandroff, quoted in N. Y. Med. Jour., 1894, ii, 341. 

3 Pearson, Brit. Med. Jour., 1891, i, 861. 

* Adam, Australas. Med. Jour., 1887, ix, 182. 



TYPHOID A BSCESSES, I 5 7 

twenty-eighth day, and on the fiftieth to have passed 
two ounces of pus by the bowel. In a third, 1 " typhli- 
tis " is said to have occurred. All three recovered. 
The following is the only similar case I have seen : 

Case XVIII. — Mrs. Mary B., age twenty-six, 
Bellewood, Pa., entered the Jefferson Medical Col- 
lege I lospital January 5, 1893. She had always been 
well until two years ago, when she had an attack of 
typhoid fever lasting for four or five weeks. In her 
early convalescence (the exact time is uncertain) 
an abscess about the size of a goose egg formed in 
the right side and opened into the ascending colon. 
She did not have very severe pain. She passed a 
considerable amount of very offensive green-colored 
pus in her stools. About two months later a second 
abscess formed lower clown than the first. It was 
very painful, and was opened by her physician in 
October, 1892. Fecal matter then began to be dis- 
charged with the pus, and a fecal fistula still exists. 

Operation, February 11, 1893. An incision was 
made parallel with Poupart's ligament, the center of 
the incision corresponding to the fistula. After a 
very troublesome dissection, the fistula was found to 
end in a somewhat globular mass under the abdom- 
inal wall. This mass was seven cm. in diameter ; 
the exterior was smooth and covered with perito- 
neum on the surface next the abdomen. On the 
other side it was attached to the surrounding tissues. 
The interior was made up of granulation tissue 
and pultaceous matter. No opening could be de- 
tected leading into the bowel. 

Unfortunately, it did not occur to me at the 
moment to inflate the colon with hydrogen gas or 
air, which would probably have shown the intestinal 
end of the fistula. I suspected that the appendix 
was imbedded in the mass ; that during the fever per- 

1 Alrich and Pepper, University Med. Mag., Feb., 1S90 



158 SURGERY OF TYPHOID FEVER. 

fo ration of the appendix had taken place ; and that this 
was the source of the fecal fistula. After searching 
as long and widely as I deemed prudent, but unsuc- 
cessfully, to find either the appendix or the opening 
into the bowel, the mass was curetted, disinfected, 
and packed. The peritoneal cavity had been freely 
opened, but the intestines were protected by iodo- 
form gauze and no ill result followed. The fistula 
slowly contracted after the operation, so that when 
she was discharged, April 22, 1893, often two or 
three days elapsed without any discharge. Her 
general health, however, was poor. She died from 
general debility nine weeks later. 

Typhoid ulcers in the appendix or caput coli may 
easily have produced such conditions, and even if no 
perforation take place, it is not impossible that the 
colon bacillus may pass through the intestinal wall 
during an attack of typhoid and produce an abscess, 
as has been frequently demonstrated in other condi- 
tions than typhoid. I believe there is no case yet 
recorded of the typhoid bacillus having been found 
free in the peritoneal cavity except where its pres- 
ence has been readily accounted for, not by penetra- 
tion through the intestinal walls, but from such 
sources as a perforation (Chap. XV), the rupture of 
abscesses of the liver (Chap. XVI), spleen (Chap. 
XVII), of the gall-bladder (Chap. XVI), or rup- 
ture of a mesenteric gland. In fact, just as in 
general surgery peritonitis is now believed to arise 
only as a positive result of a direct injury or of some 
usually demonstrable lesion in an abdominal organ, 
so peritonitis during or after typhoid fever always 
has a similar positive, but not always a demonstrable, 
cause. In a number of other cases perforation has 



/ ) PHOID A BSCESSES. I 59 

been suspected as the cause of an abscess without 
its being possible to be sure of one's ground. Thus, 
in Major's case, 1 on the eighteenth clay the symp- 
toms of collapse occurred. Three weeks later an 
abscess burst through the rectum, and the patient 
recovered. The author believes that a perforation 
led to the abscess. In Low's case, 2 in the third week 
the symptoms of collapse and peritonitis led the 
author to diagnosticate a perforation. These symp- 
toms gradually subsided, and finally a residual ab- 
scess burst through the abdominal wall, gave vent 
to horribly fetid pus, and this patient also recovered. 
While both very likely resulted from a perforation, 
recovery prevented demonstrative proof. They are 
good illustrations of the witty dictum that " no case 
is complete without a post-mortem." 

This complete proof, unhappily, however, is not 
always wanting. Thus, in a case of Lehmann, 3 in 
the third week perforation occurred. The patient 
died at the end of a month, and the healed scar of 
the perforation and the resulting encapsulated ab- 
scess were both found. There was also a suppura- 
tive parotitis due to a mixed staphylococcus and 
typhoid infection. The pus of the abdominal abscess 
showed a pure culture of Eberth's bacillus. This 
fact is worthy of especial note, as the perforation pre- 
sumably gave ready exit to the colon bacillus. In 
another case 4 a man of twenty-five, just recovered 
from scarlatina, suffered from a mild attack of 
typhoid. At the necropsy, only six Peyer's patches 

1 Brit. Med. Jour., 1891, i, 18. 2 Brit. Med. Jour., 1SS1, ii, 122. 

3 Centralbl. f. klin. Med., 1891, 649. 

4 Potain, Gaz. des Hop., June 9/1891, 621. 



160 SURGERY OF TYPHOID FEVER. 

were found to be inflamed, but all extended to the 
peritoneal coat of the bowel. He perished from 
a perforation which, not having any prior protective 
inflammation, led to general peritonitis, as in so many 
cases of perforative appendicitis without adhesions. 
In Eisner's case, 1 in spite of such a protective peri- 
tonitis marching in front of perforation, the patient, 
a young man of twenty-seven, died from profuse 
hemorrhage. 

Tiingel 2 relates a case in which a suppurating 
mesenteric gland near the cecum gave rise to an 
abscess which perforated a branch of the superior 
mesenteric artery and caused death. 

Perforation of the rectum has already been men- 
tioned (p. 159, Major's case). In this case a pelvic 
abscess burst into the rectum. 

Case XIX. — The following case of ischio-rectal 
abscess following typhoid, perforating the rectum 
and resulting in a fistula, is kindly furnished me by 
Dr. I. C. Schureman, of Toms River, N. J. : 

Miss X., age twenty, had a severe attack of 
typhoid fever for six weeks in the spring of 1897. 
In the third week she complained of intense pain in 
the region of the anus and sacrum. A few days later 
an abscess was discovered, and was opened half 
an inch to the left of and posterior to the anus, giving 
vent to a large quantity of very offensive pus. In 
the fourth week of the fever another point of fluc- 
tuation was discovered three inches above the anus 
near the sacrum. The pus was evacuated, and the 
two abscesses were found to communicate with each 

1 Trans. Med. Soc. State of N. Y., 1892, 314. 

2 Klin. Mittheil. aus dem Kaiserlich. Hamburg, allgemein. Krankenh., 
Hamburg, 1S64 ; quoted by Langenbuch, Deutsche Chirurgie, Leif., 45 c. 
Erste H&lfte, 238. 



TYPHOID ABSCESSES. l6l 

other. The tissues over the left natis near the 
anus sloughed over an area \yi inches in diameter, 
and were a long time in healing after convales- 
cence was established. Her vitality was so low that 
nothing further than symptomatic treatment could 
be carried out. She was advised to enter a hospital 
after she entirely recovered, in order to have the 
abscess fully laid open and treated, but declined to do 
so. In July, 1897, during an absence from home, she 
was very ill for several weeks. Ten days after the 
illness began she passed pus from the rectum for 
three days, and has passed it at intervals ever since 
until a month ago (November, 1897), when it appar- 
ently ceased. During her convalescence she suf- 
fered a great deal of pain in the lower abdomen, but 
only a small amount of pain in the rectum. 

But the results are not always so happy, especially 
when the perforation proceeds from within outward. 
In one case, 1 on the forty-first day, as a result it was 
supposed of cough, a perforation occurred on the 
anterior face of the rectum (sigmoid flexure ?), nine 
inches from the anus. The case resulted fatally. 
Another case 2 of perforation of the anterior wall 
was followed by further complications, but finally 
ended in recovery. The perforation of the rectum 
occurred between the twelfth and the twentieth days, 
and resulted in a pelvic stercoral abscess. Between 
the thirty-sixth and the forty-fourth days this abscess 
burst into the bladder. The feces, it is surprising to 
note, gave rise to no special trouble in the bladder. 
The case was operated on by the gorget and thermo- 
cautery. The opening in the bladder then healed 
spontaneously, and the patient recovered. 

1 Cockle, Lancet, 1882, i, 178. 

2 Debongnie, Arch. Med. Beiges, 1893, 225. 



1 62 SURGERY OF TYPHOID FEVER. 

Still another case x shows the extensive ravages 
which may result from a perforation of the rectum. 
In a man of thirty-six, a posterior perforation of the 
rectum on the twenty-sixth day was followed by an 
abscess in the meso-rectum, and finally led to his 
death by erosion of a hemorrhoidal artery. (Cf. 
Tungel's case above.) But this was far from all : 
the left leg was swollen and emphysematous all 
the way to the ankle. The post-mortem explained 
the reason. Pressure on the leg forced fluid and 
gas from the leg into the pelvis. The pelvis was 
full of feces, and the abscess had burrowed its way 
out of the pelvis between the pyriformis and the 
gemelli into the thigh after perforating the pelvic 
fascia. A pelvic abscess in a case of Bosnieres 2 
also burst through the vagina in a young woman of 
eighteen. Though she suffered also from necrosis 
of both tibiae, she made a good recovery. 

Another cause of such an "abdominal abscess" is 
a suppurating mesenteric gland. Of this, too, the post- 
mortem table has given us convincing proof. Thus, 
in a case of Lehmann, 3 an abscess due to such a 
gland was found, and the pus show r ed a pure culture 
of Eberth's bacillus. In Fraenkel's case 4 an abdom- 
inal abscess was due, presumably, to a mesenteric 
gland, four and a half months after the onset of 
the fever. This first attack had been followed by 
two relapses, by facial erysipelas, and in the seventh 
week by symptoms of perforation. The abdomen 
was opened and \y 2 liters of pus evacuated, in 

1 Pryor, Buffalo Med. and Surg. Jour., 1881-82, xxi, 555. 

2 These de Paris, 1890. 3 Centralbl. f. klin. Med., Aug., 1891, 649. 
4 Verhandl. Kongress inner. Med., 1887, 179. 



TYPHOID A BSCESSES. 1 63 

which only the typhoid bacillus was found. The 
patient died later of ileus. 

In at least one other case the proof has been at- 
tained by an abdominal section which, instead of fol- 
lowing, prevented the patient's death. Michie, 1 by 
a timely section in the fourth week, evacuated and 
drained an abdominal abscess due to such a sup- 
purating gland. Thomson, 2 by the aspirator, re- 
moved five drams of grumous matter, which the 
author attributed probably to a mesenteric gland. 
The case is obscured, not only by the mode of treat- 
ment, — which, however, a happy recovery fully justi- 
fied, — but also by the fact that the patient was of a 
strumous predisposition, and eight days before the 
development of the disease (which was about the 
period of defervescence) had wrenched his back. 
Low's case 3 was very likely a similar one. In the 
fourth week after defervescence the temperature 
gradually rose ; a lymphatic gland in the neck sup- 
purated ; a tumor as large as a cricket ball formed 
to the ricrht of the umbilicus and discharged into the 
bowel. 

The following case of subdiaphragmatic abscess is 
the only one I have found: 

Case XX. — Klein 4 reports a case of left-sided sub- 
phrenic abscess, probably arising from the spleen, 
following typhoid fever, in which the typhoid bacillus 
was found in pure culture in the pus. 

A man, age thirty-four, on June 24, 1895, fe^ ^ 

1 Brit. Med. Jour., 1S88, i, 1388. 

2 Glasgow Med. Jour., 1 882, xvii, 244. 

3 Brit. Med. Jour., 18S1, ii, 122. 

4 Ueber die Pyogene Wirkung des Eberthschen Bacillus bei Typhuskom- 
plikationen, Inaugural Dissertation, Bonn, 1896. 



1 64 SURGERY OF TYPHOID FEVER. 

after drinking some stagnant water. By the 3d of 
August he was free from his fever and left his bed 
on the 8th. On the 13th he again went to bed 
with a temperature of 103 , with increased dulness 
over the spleen, but without tenderness. From this 
date the dulness and a distinct tumor in the region 
of the spleen increased. On his admission into the 
hospital, under the care of Dr. Schmidt, on the 2 2d 
of Augaist, the left lower half of the thorax was 
markedly rigid in the line of the nipple, with but 
little respiratory movement upon that side of the 
chest. The dulness posteriorly began at the lower 
border of the scapula. Nothing abnormal in the heart. 
The diagnosis was made of a subdiaphragmatic ab- 
scess, probably arising from the spleen. Aspiration 
on the 23d of August showed the presence of pus. 
On the 26th of August Dr. Sartoris operated. A 
portion of the seventh rib was removed in the axil- 
lary line. A puncture was made and pus was 
found. The puncture showed, however, that access 
to the suppuration was not direct, but that the 
pleura lay between. Accordingly, the costal pleura 
was opened without disclosing any pus. The dia- 
phragmatic pleura was seen to be markedly arched 
forward and was in direct contact with the costal 
pleura, but without any adhesions. The two layers 
of the pleura were carefully sutured and an incision 
was then made into the abscess, which discharged a 
thinnish, clear brown pus without any fecal odor. A 
catheter was introduced, and by means of this a 
second incision for drainage was made above and to 
the left of the umbilicus. The amount of pus evacu- 
ated was three liters. The surgeon endeavored to 
recognize the spleen, but neither this nor any other 
viscus was recognizable. The wound was drained 
and the patient made an excellent recovery. The 
bacteriological examination seems to have been 
made with great care, and showed only typhoid 
bacilli, and the author adduces the case as an excel- 



TYPHOID ABSCESSES. [65 

lent evidence of the pyogenic faculty of the typhoid 
bacillus. 

Of the symptoms and treatment of these ab- 
scesses I need not say much, as they differ little if 
any from the symptoms and treatment of similar 
ordinary abscesses. Any operation during or im- 
mediately after so serious a (^v^r as typhoid is to be 
deprecated unless it be unavoidable. The dangers 
of either alone may be great, but of both combined 
must be great. But, on the other hand, to allow a 
patient to die from an abscess, be it in the abdo- 
men, the neck, the thigh, the buttock, or elsewhere, 
is still more to be deprecated. Unless, therefore, 
the associated conditions prohibit it, such abscesses 
should be treated, on general surgical principles, by 
antiseptic evacuation and, usually, drainage. The 
need for strict disinfection is especially evident, since 
if it be not carried out we may add a staphylococcus 
or, worse still, a streptococcus infection to an existing 
typhoid infection, and further and gravely imperil the 
patient's chances of recovery. 



CHAPTER VII. 
TYPHOID HEMATOMATA. 

It is rather strange that while in the earlier table 
(see Toner Lecture, " Hematomata ") I was able to 
collect so many cases of hematoma, in the second 
collection, even larger than the former, Dr. West- 
cott found only 17 cases. These add but little to 
the facts collected in the Toner Lecture. I must, 
therefore, refer the reader to that chapter, adding 
only a few data. 

The abdominal wall was, as before, the principal 
seat of the degeneration. The recti were involved 1 3 
times, the " abdominal wall " twice, the great pectoral 
and the superficial muscles of the neck each once. 
The last patient died of septicemia. All the cases 
followed typhoid. 

The ages of these patients were much below 
those of the former series, as nine of them were 
from fifteen to twenty-five and six were over twenty- 
five, the oldest being thirty-nine. There were 13 
males to three females, a larger proportion of males 
than in the earlier table. Two arose during the 
third, fourth, and fifth weeks, two two months and 
one in the fifteenth week after the fever, three weeks 
after a relapse. Three were only discovered at the 
post-mortem. Of seven treated properly by incision 
and drainage none died. Of six, in which no mention 
is made of an incision, all died. 

166 



TYPHOID HEM A TO MA TA . 1 67 

The following case is the only one I have person- 
ally seen. 

Case XXL — Abscess of the abdominal wall and 
pelvis after typhoid fever. 

D. C, age twenty-seven, was admitted to St. 
Agnes' Hospital June 29, 1891. On March 7, 1891, 
he had been taken sick with typhoid fever and was 
in bed until April 27th. On May 29th he again fell 
ill with what was pronounced a relapse. About 
June 20th he suffered considerable pain in the 
lower abdomen. This was soon followed by swell- 
ing, which increased quite rapidly. On admission, 
nine days afterward, a swelling 9 cm. long was 
found just above the pubes, apparently in the right 
rectus. It was quite tender. His temperature was 
102 . Unfortunately, I did not examine it by the 
rectum, and therefore can not state the condition 
of the pelvis. As the skin was in a very bad con- 
dition from the constant application of iodin, I 
applied an antiseptic fomentation to the part, both to 
relieve his pain and to remove the shreds of skin, 
as there seemed to be no urgency in his case. July 
4th I made an incision into the abscess, and found 
that it not only occupied the muscle, but also ex- 
tended into the lower abdomen and pelvis, reaching 
to the bladder and the rectum. It had not, however, 
ruptured into the peritoneal cavity, but had pushed 
the peritoneum before it. Over a pint of pus was 
evacuated and the cavity was then drained with a 
rubber drainage-tube. In a little over twenty-four 
hours the temperature fell to normal, and in twelve 
days he went home. 

It is gratifying that recovery followed in spite of 
the extensive mischief wrought before operation. 
This is partly due, probably, to the late period at 
which it arose. I have ventured to place it here 



1 68 SURGERY OF TYPHOID FEVER. 

under the head of hematoma, though it may have 
been an abscess in the abdominal wall and not have 
originated in a hematoma properly so-called. Its 
position, however, strongly suggested hematoma. 
Unfortunately, no facilities existed at the hospital at 
that time for a bacteriological examination. The 
bacillus of Eberth, however, has been found in the 
pus of a similar abscess by Raymond and Strauss. 1 

1 Pein, These de Paris, 1891, 58. 






CHAPTER VIII. 
CEREBRAL COMPLICATIONS OF TYPHOID FEVER. 

I have already alluded to three cases of obstruc- 
tion of the Sylvian artery (Gangrene, p. yy). All 
three were on the left side, and were probably 
thrombotic rather than embolic in origin. In one of 
them, a case of ambulant typhoid, 1 there was tuber- 
cular meningitis in a woman six and one-half months 
pregnant, and it may be that the Sylvian obstruction 
was not of typhoid origin at all. Osier 2 has pub- 
lished an excellent paper upon hemiplegia in typhoid 
fever. Haines 3 has also reported a case. 

The other cases of cerebral complications are 
19 in number, 4 of abscess and 15 4 of meningitis. 
One of the cases of abscess, an " abscess of the men- 
inges" (see below), perhaps should be classed as a 
meningitis. In the 15 cases of meningitis, both the 
dura and the pia were attacked indifferently, and 
the exudate was sometimes serous, sometimes sero- 
purulent, but in at least 6 of the cases was puru- 
lent. In two (Ohlmacher, vide infra) there were 
also 120 c.c. and two ounces of blood clot. 

It is noteworthy that a bacteriological examina- 
tion was made in all 15, and that without ex- 
ception the bacillus of Eberth was found — in 12, 

1 Huguenin, Correspondenzbl. schweiz. Aerzte, 1879, 449- 

2 Jour. Nervous and Mental Diseases, May, 1896. 

3 Bull. Johns HopkinsHosp., 1896. 4 Besidesthe case on p. 152, footnote. 

169 



I/O SURGERY OF TYPHOID FEVER. 

it is expressly stated, " in pure culture." Wolff 1 
has collected 174 cases of meningitis in which a 
bacteriological examination was made and bacteria 
were found in all but 1.15 per cent. In 2.87 per 
cent, the bacillus of Eberth was found. In one of 
Ohlmacher's cases a mixed streptococcus and typhoid 
infection was found. In two cases 2 the patients 
died so shortly after the cerebral symptoms began 
that, as the author of one 3 points out, there was not 
time enough for other bacteria to have set up the 
meningitis and then to have disappeared. 

Two of the cases 4 are referred to on page 47 as 
asserted cases of typhoid infection without the char- 
acteristic typhoid lesions in the intestine. 

In no one of the four cases of abscess w T as a bac- 
teriological examination made, a most unfortunate 
omission. All of them occurred during or after 1884, 
and the bacillus was then well known. Of these 
four cases a resume is given at the end of this 
chapter. 

Two of the 3 Sylvian cases died and every one of 
the other 19. The dates of onset are significant. 
Of the whole 19 cases, 1 of the Sylvian and 5 of 
the meningeal cases arose in the third week ; the 
other 2 Sylvian cases arose, one "in the course" 
and the other on the twenty-third day, two days 
beyond the third week. Three arose in the first 
week and one in the seventh week. Four of the 
meningeal cases were discovered at the post-mortem. 

1 Berlin, klin. Wochen., 1897, No. 10. 

2 Kamen, Internat. klin. Rundschau, 1890, Nos. 3 and 4 ; Fernet, Bull. 
Soc. Med. des Hop., 1891, 361. 

3 Kamen, he. eit. 4 Balp and Adenot. 



CEREBRA I. COMPL/C I TIONS. i 7 i 

Practically, therefore, of these 16 cases 7, and possi- 
bly more, arose in the third week, when the fever 
would be at its height. 

( )f the 4 cases of abscess, 1 arose " in the course " 
of the fever, and the 3 others on the fifty-sixth, 
fifty-seventh, and ninety-eighth days, two to three 
months after the fever. 

Sex. — Of the 19 cases, 12 were males and 7 
females. 



Age: 



Under twenty there were, 6 cases. 

From twenty to thirty there were, ... 8 " 

Thirty-one, 1 case. 

Thirty-three, 

Forty-four, 

Fifty-seven, 

Soldier (an adult), 



19 cases. 

The subjoined resumes of three cases of typhoid 

meningitis by Ohlmacher are the most recent and 

the most carefully investigated cases that have come 

under my notice. It will be observed that one was 

due to a mixed infection, but in two a pure culture of 

the typhoid bacilli was obtained. In one in which 

suppuration occurred a distinct endarteritis was 

found (Plate II). This fact is not only important 

in its bearing on the pathology of typhoid meningitis 

which has reached the suppurative stage, but it is 

possible that it may throw some additional light on 

the production of the form of gangrene alluded to 

on pages 63 and 70. It is true that in such gangrene 

there is no suppuration so far as we know, but it at 

least suo-crests t } ie neet j f or more accurate investiga- 
tes o 



172 SURGERY OF TYPHOID FEVER. 

tion to determine whether it is not possible that en- 
darteritis may occur in the extremities, especially in 
the le^s, and thus lead to a-ano-rene. 

Case XXII. 1 — Man, age twenty-five, died on 
the seventeenth day after admission, in the fourth 
week. At the necropsy typical typhoid ulcers cor- 
responding to the fourth week were found in the 
ileum, with swollen mesenteric glands. When the 
head was opened he found meningitis and 120 c.c. of 
blood on the right side, with edema and a cloudy pia 
with yellowish flakes. The typhoid bacilli were 
found in the spleen, mesenteric glands, bronchial 
glands, and in the pia in the region of the hemor- 
rhage. 

Case XXIII 2 — Man, age forty-six, died in the 
fourth week. The spleen was swollen to twice its nor- 
mal size and was quite soft. In the brain was found 
a leptomeningitis, with 40 c.c. of turbid fluid in the 
distended lateral ventricles. The typhoid bacilli were 
found in the lung, the spleen, the mesenteric and 
bronchial glands, and the pia. " Countless myri- 
ads " were found, on microscopical section of the 
brain, in the pia, arachnoid, and in the meningeal 

1 Ohlmacher, Jour. Amer. Med. Assoc, Aug. 28, 1897, p. 419. 

2 Ohlmacher, loc. cit. 



Suppurative Typhoid Leptomeningitis. (Explanation of Plate II.) 

Fig. 1. — Portions of two cerebral gyri with intervening sulcus and meningeal cov- 
ering; meningeal membrane filled with inflammatory exudate. Small branch of 
middle cerebral artery seen in cross-section, showing endarteritis. Photographed 
with Leitz obj. 2, oc. 1. 

Fig. 2. — Portion of arachnoid membrane from same section as Fig. 1, showing num- 
erous typhoid-bacilli. Drawn from a photograph with Leitz obj. fa, oc. 1. 

Fig. 3. — From same series of sections as Fig. 1. Branch of middle cerebral artery 
showing acute endarteritis. Note the inner bounding membrane (endothelium) and 
the numerous small cells between it and the intima. Some of the small cells are also 
seen within the endothelial lining. Photographed with Leitz obj. 7, oc. 4. 

Fig. 4. — From another series of sections of the cerebrum in same case. Branch of 
middle cerebral artery showing complete obliteration of lumen by endarteritis. Same 
power as Fig. 3. 

.Fig. 5. — Same section as Fig. 1. Minute arteriole of middle cerebral artery, show- 
ing endarteritis. The endothelium is raised well into the lumen. There is moderate 
sub-endothelial cellular proliferation ; a few cells lie within the lumen. Leitz obj. fa, 
oc. 4. 

[Reproduced from A. P. Ohlmacher's paper (Jour. Amer. Med. Assoc, Aug. 28, 
1897) by the kind permission of the author and editor.] 



PLATE II. 





I 







, - &u ' * 



W^ : 9 



v 





CER EB A'. I L COMPLICA TlOh r S. 1 7 3 

exudate. Extensive obliterating endarteritis was 
present. 

Plate II is taken from Dr. Ohlmacher's paper, 
with his kind permission, and shows admirably the 
meningeal exudate, and especially the endarteritis, 
as seen in the preceding case. 

Case XXIV. 1 — A woman, age twenty-four, who 
died at the end of the second week, having had tonic 
spasm of the flexor muscles, especially marked on the 
left side, preceding death. The necropsy showed 
three spots of ulceration in Peyer's patches. There 
was beginning left-sided broncho-pneumonia. On the 
right side of the brain there was acute pachymen- 
ingitis with about two ounces of clotted blood and a 
catarrhal leptomeningitis. In the blood from the 
heart were found cultures of the streptococcus. [It 
is surprising, in view of this, that there was no infec- 
tive endocarditis.] In the spleen and mesenteric 
glands and in the blood of the heart he found pure 
typhoid bacilli. In the subdural space and in the 
pia he found the streptococcus and typhoid bacillus 
as a mixed infection. The streptococcus infection 
probably reached the brain by way of the lungs. 

These three cases are particularly interesting by 
reason of the very careful microscopical and bacterio- 
logical examination which was made. 

In the bacteriological examination a reference to 
his paper will show that he used all the more modern 
tests for differentiating the typhoid and the colon 
bacilli from each other, and the identification of the 
typhoid bacillus in the brain seems to be undoubted. 

The microscopical examination is quite as interest- 
ing. In Case XXIII he found an "exquisite and 

1 Ohlmacher, Cleveland Med. Gaz., May, 1897, 409. 



174 SURGERY OF TYPHOID FEVER. 

wide-spread acute endarteritis affecting the smaller 
arteries of the pia in both the anterior cerebral and 
the cerebellar regions ; in other words, an endar- 
teritis involving at least the branches of the middle 
cerebral and anterior cerebellar arteries. The pro- 
cess affects both the medium-sized and the smaller 
arterial branches, and varies from a partial to a com- 
plete obliteration. Serial sections from one of the 
larger vessels shows the advance from a partial to a 
complete obliterating endarteritis (Plate II). In the 
more minute twigs the change most frequently results 
in complete obliteration, and the newly-formed tissue 
fills the lumen of the vessel. The study thus far 
made of this condition seems to point to the con- 
clusion that the endothelium of the intima is raised 
from its bed and forced into the lumen of the vessel 
by a sub-endothelial exudate ; at least, a distinct 
membrane with fusiform nuclei can be found in the 
vessels in which the obliteration is not complete, 
bounding the new cells internally ; and where the 
occlusion is complete a central core of cells, with 
laterally compressed nuclei, seems to be the same 
membrane forced into a compact mass. Two dis- 
tinct kinds of small cells, both poor in protoplasm, 
are to be found in the endo-arterial exudate, one with 
nuclei composed of compact deeply staining chro- 
matin, and engaged in one or another of the stages 
of indirect fragmentation ; while the others, com- 
paratively less numerous, are slightly larger and 
possess single nuclei with the chromatin more dif- 
fused. These small cells do not differ in structure 
from the pus cells of the general extravascular 
meningeal exudate, and are united by delicate proto- 
plasmic fibers which seem to bind the cells together 
by a delicate reticulum, though they are often sepa- 
rated some distance from each other." 

No bacilli were found in the arteries, though they 
were "abundant about the arteries, even to the ex- 



( EREBRAL ( OMPLICA TIONS. 175 

tent of invading the perivascular lymph space, but 
they seem to be effectually barred by the muscular 

media." 



The symptoms of cerebral involvement, especially 
of meningitis, are often overlooked. They are 
masked by the general stupor, and are supposed to 
be only connected with the usual delirium of typhoid. 
That only 15 cases of typhoid meningitis were found 
in such an extensive tabulation is remarkable. I 
am strongly disposed to think that such cases have 
been frequently overlooked by reason of the fact 
that the head is not very often opened in typhoid 
necropsies unless the cerebral symptoms have been 
very prominent. Even in cases without marked 
cerebral symptoms, examination of the brain, I be- 
lieve, will show meningitis and infection by the bacilli 
of typhoid to be far more frequent than has been 
supposed heretofore. 

Whether anything can be done by the surgeon to 
relieve such a complication is very doubtful, in my 
mind. Trephining would be useless, as the infection 
is too wide-spread. If I am right in this view, surgery 
has nothing to offer in such cases. 

In abscess of the brain the symptoms are more 
pronounced, and may indicate both the nature of the 
lesion and occasionally even its location. When a 
hemiplegia or a monoplegia occurs, while it may be 
due to thrombosis, it should also raise the question 
of the possibility of abscess. If the eye symptoms 
point to this complication (optic neuritis), it would be 
confirmatory. But in cerebral abscess this is often 
wanting. The fever accompanying the disease itself 



iy6 SURGERY OF TYPHOID FEVER. 

would cause a rise of temperature, which generally 
is absent in ordinary cerebral abscess, and this will 
obscure the diagnosis. The same may be said of 
headache, which so constantly accompanies typhoid, 
especially of the cerebral type. Cerebral vomiting 
also would be ascertained with difficulty. On the 
whole, therefore, the diagnosis is difficult, and may 
be impossible. 

Even if a fairly positive diagnosis can be made it 
is doubtful whether trephining would offer any loop- 
hole of escape from death. Yet, on the other hand, 
every such case so far has died, and at least no 
worse result could follow an attempt to relieve such 
a hopeless condition. Only of late have surgeons 
had the boldness to interfere in cases of biliary and 
intestinal perforation, and with at least fair results. 
Possibly the same may be true in the future, if we 
attempt to rescue also the cases of cerebral abscess. 
I should be inclined, at least, to try. Fortunately, 
as our tables show, such a complication is exceed- 
ingly rare. 

I append a resume of the cases of abscess of the 
brain, at least for our information and as food for 
reflection. 

I also add an unusual case of thrombosis of the 
intracranial veins without involvement of the sinuses 
but with three small abscesses (?) of the brain. 

Case XXV — Holscher 1 simply alludes to one fatal 
case of abscess of the frontal lobe of the brain in a 
patient aged twenty-four. 

Case XXVI. — Josserand 2 reports a case of a 
young girl of twenty who died of suppurative menin- 

1 Munch, med. Wochen., 1891.N0. 4. 2 Lyon Med., 1894, vol. lxxvi,97. 



CEREBRAL COMPLICATIONS. 177 

gitis in typhoid fever. She had moderate aphonia and 
right monoplegia ; death followed forty-eight hours 

after the cerebral symptoms began. At the ne- 
cropsy recent meningitis was found over the left 
lobe. It had its origin in an abscess as large as an 
orange at the base of the second frontal and the 
ascending frontal and parietal convolutions. It had 
depressed the cerebral substance without altering 
the convolutions, which were perfectly recognizable. 
The patient had a slight excoriation over the sac- 
rum, only involving- the epidermis and without sup- 
puration. No bacteriological examination appears 
to have been made. 

Case XXVII. — Deschamps l reports the case of a 
man, age nineteen, who entered the hospital Decem- 
ber 4, 1893, w i tn ordinary typhoid fever. On the 
31st he had a relapse. By February he had entirely 
recovered, excepting for a persistent diarrhea. The 
temperature had become normal. On the 14th of 
February a pleurisy with effusion was observed. The 
patient began to grow weaker and showed signs of 
tuberculosis at the left apex. On the 28th of Feb- 
ruary he complained of severe pain in the right ear 
and the right face, with difficulty in deglutition, and 
facial neuralgia W as diagnosticated. There was 
nothing abnormal in the throat. By the 2 2d of 
February his temperature had become normal. 
On March 1st, about the ninety-eighth day, it rose 
to 39-3° C. On the 2d, though it had fallen to 
37. 2 , a paresis of the right hand manifested itself. 
There was no paresis of the left arm. There was 
no disturbance of sensibility. The facial neuralgia 
persisted, and the patient for several clays had bilious 
vomiting. He died on March 4th. The necropsy 
showed a serous pleurisy of the left side ; tuber- 
culosis of the left apex ; a normal heart, liver, kid- 
ney, and spleen ; congested, cicatrized, and thickened 

1 Progres Med., 1S84, vol. xii, 950. 



178 SURGERY OF TYPHOID FEVER. 

Peyer's patches in the intestine. There was no men- 
ingitis, but an abscess of the brain was found on 
the right side at the posterior portion of the first 
temporal convolution. It did not communicate with 
the ventricles in the left hemisphere ; there was no 
lesion of the ear on the riant side. 

o 

Case XXVIII. — Huchard and Tissier * report the 
case of a man, age fifty-seven, who suffered with all 
the classical symptoms of typhoid fever. He had a 
slight trace of albumin in the urine ; his hebetude was 
very pronounced, but was more apparent than real on 
account of his typhoid deafness. He entered the 
hospital April 21, 1884, about twelve days after his 
illness began. He was obliged to remain in the 
hospital for six weeks on account of his slow conva- 
lescence, but without any complication that was per- 
ceptible until the 5th of June (fifty-seventh day) when, 
after an elevation of temperature, complete aphasia 
set in, with paralysis of the right side of the face. 
On the next day the arm was paralyzed ; on the 
second day the leg of the right side was paralyzed ; 
the paralysis in both being not quite complete. Sen- 
sation was diminished. The patient did not complain 
of his head, had not vomited, had no albuminuria, 
no valvular lesion. His belly was distended and 
the diarrhea had not ceased. On the 7th of June 
speech partially returned and his paresis dimin- 
ished. On the contrary, his intellectual state became 
much worse. His torpor was excessive, so that he 
could scarcely be roused by any question. He died 
on the nth of June. The necropsy showed that 
the heart was normal ; the intestinal lesions of 
typhoid were marked. At the middle and upper 
portion of the left hemisphere a localized meningitis 
existed, which had resulted in an abscess of the 
meninges, 12 by 5 cm. The convolutions under- 
neath the abscess were flattened out. The portion 

1 Progres Med., 1885, vol. xiii, 440. 



CEREBRAL COMPLICATIONS. I 79 

of brain involved was the frontal and parietal lobes, 
especially the ascending frontal and parietal and 
the second and third frontal convolutions near the 
fissure of Rolando and the two parietal lobes. The 
contents of the abscess were between 50 and 60 
gm. of green, creamy pus. There was no evidence 
of ecchymosis or infiltration. The abscess existed 
between the dura and the arachnoid. There was no 
suppuration in the petrous bone. 

Case XXIX.— Dr. A. B. Richardson ' relates an 
interesting case of marantic thrombosis of the intra- 
cranial veins following typhoid fever, without throm- 
bosis of the sinuses. The patient was a man aged 
forty-three, who had had two injuries, one on the 
right side of his head twelve years before, the 
other on the left side of his head three months 
before, but without any cerebral symptoms except 
more or less headache. Toward the end of the 
third week defervescence took place. Just at that 
time, however, he began to complain of intense pain 
in the left temporal region, with, later, subnormal 
temperature and collapse, contraction of the pupils, 
somnolence, delirium, and convulsive movements in 
the left arm and leg and right face, and, later, on 
the right side of the body. Operation was con- 
sidered, but decided against in view of the too dif- 
fuse and uncertain symptoms. The case was 
diagnosticated as probably one of acute meningitis. 
The eye grounds showed only general engorgement, 
more pronounced on the left side. He died at the 
end of about a week. 

The necropsy showed no signs of meningitis, but 
the principal veins on the surface of the cortex were 
distended with hard clots ; one of particularly large 
size lay along the fissure of Rolando. In the first 
temporal convolution of the left side was an area 
the size of a hickory-nut, which broke open, dis- 

1 Jour. Nerv. and Ment. Dis., July, 1897, p. 404. 



l8o SURGERY OF TYPHOID FEVER. 

charging a small amount of pus and broken-down 
brain tissue and blood coagula as the brain was 
removed. On the right side of the brain, just in 
front of the Rolandic fissure at its middle and upper 
third, was another area of a similar character though 
less advanced. In the right occipital lobe was another 
area, but not yet softened. The sinuses were en- 
tirely free. Unfortunately, no bacteriological exami- 
nation or microscopical examination seems to have 
been made. Whether the collapse was the cause 
or the result of the thrombosis is uncertain. 






CHAPTER IX. 
OTITIS MEDIA IN TYPHOID FEVER. 

Dr. Westcott has collected 31 cases, of which 24 
are reported by a single observer. 1 Since the table 
was completed Hengst 2 has added 28 cases out of 
1228 cases of typhoid collected from the practice of a 
large number of physicians — an average of about 2.5 
per cent. Very likely many observed cases have 
not been deemed important enough to record. 
Only one case of mastoid disease was observed 
(Hengst) in all the 59 cases. 

The usual cause is obviously a pyogenic infection 
from the throat. The diplococcus of pneumonia 
has also been found. In two bacteriological ex- 
animations 3 the bacillus of Eberth was not found, 
but its presence has been shown by Destree and 
Vincent (p. 26). The infection, however, would be 
more likely to be pyogenic, access to the middle ear 
beino- obtained through the Eustachian tube. Cold 
draughts or cold water in the ear from bathing the 
patient may, as Hengst believes, occasionally cause 
the trouble, but I would hardly attribute much im- 
portance to them as compared with the infection from 
the air-passages. 

The disease is a complication rather than a sequel. 

1 Sorel, Soc. Med. des Hop., 3d series, vi, 1889, 224. 

2 N. Y. Med. Jour., June 6, 1896. 

3 Dunin, Deutsch. Arch. f. klin. Med., 18S6, xxxix, 369. 

l8l 



182 



SURGERY OF TYPHOID FEVER. 



It arises usually in the second to the fourth week, 
when the patient is at his lowest ebb. The mouth 
and naso-pharynx are filled with mucus, which the 
patient is too weak or too indifferent to expectorate, 
and the same region is not seldom also the seat of 
ulcers which add pus to the mucus. Though, as Sorel 
points out, this complication usually accompanies 
mostly grave and prolonged cases, yet not a single 
death is recorded among the 59. 

The symptoms and treatment call for no special 
remarks. 



CHAPTER X. 
TYPHOID PAROTITIS. 

It is a noteworthy fact that in the later and larger 
series of cases Dr. Westcott only tabulated 50 cases 
of parotitis as against 378 in the Toner Lecture. 
I must, therefore, refer the reader to the Toner 
Lecture for the chief facts in relation to parotitis. 

The difference in the numbers is easily explained 
when it is noticed that in the earlier series 362 
followed typhus, a far more septic disorder than ty- 
phoid, and only 26 followed typhoid. In the pres- 
ent table all but one followed typhoid. The death- 
rate in the cases in which the result is stated is 
nearly 30 per cent., for of 28 cases, 8 died. Twenty 
of the 28 in which the sex is named were males. 
Of 25 cases the average age was nineteen years, an 
earlier a^e than the former series, and nine of them 
were children under fifteen. Suppuration was much 
more frequent in the present series, for of 34 cases, 
29 suppurated and only 5 did not. In 12 cases the 
parotitis was bilateral, of which 7 suppurated on 
both sides. 

The cause of the parotitis is undoubtedly gener- 
ally a secondary infection by the pyogenic bacteria, 
which find many open ports of entry in the fissures 
of the lips, abrasions in the mouth, and a direct path 
by the duct of the parotid. In at least two cases, x 

1 Janowski, Centralbl. Bakteriol. und Parasitenk., 1 895, xvii, 685 ; Leh- 
mann, Centralbl. klin. Med., Aug., 1891, 649. 

183 



1 84 SURGERY OF TYPHOID FEVER. 

however, the bacillus of Eberth was found. In the 
last case it was associated with the staphylococcus, but 
in Janowski's case the typhoid bacillus existed alone. 
The patient was a man of twenty, who died in the 
second or third month of the fever. The suppura- 
tive faculty of the bacillus and its late ravages are 
thus once more demonstrated. 

Doubtless, very many cases of parotitis have es- 
caped notice in the histories, which would give the 
more salient points and omit a detail such as this. 
In very many cases, also, the titles have not named 
parotitis as a complication, and thus they have not 
been tabulated. 

The treatment is the usual one for such compli- 
cations — abortive, if possible by ice, iodin, ichthyol, 
etc. ; but if suppuration occur, a free antiseptic in- 
cision and drainage. 

The following case of continued sweating in the 
parotid region after a typhoid parotid abscess I 
owe to the courtesy of Prof. Osier. While not 
strictly surgical, it is sufficiently rare and curious to 
be made a matter of record. 

Case XXX. — " B. F. A., age twenty-six, applied 
to the Johns Hopkins Hospital January 18, 1896, 
complaining of sweating over a limited area on the 
right side of the face and forehead. The patient 
had typhoid fever in September, 1890. During 
convalescence an abscess formed in the right parotid 
region, and was opened. Three or four months 
after the healing of the wound the patient noticed 
profuse sweating over the right side of the face and 
temple when eating, and he has been troubled with 
it ever since. When seen the patient was a healthy- 
looking, active man. There was a scar of the inci- 



TYPHOID PAROTITIS. 



I8 5 



sion at the angle of the jaw two cm. in length. It 
was a little thickened and indurated, and slightly 
sensitive on pressure. Simple movement of the 
jaw, as in the act of mastication, produced no sweat- 
ing. The chewing of food, more particularly on the 
right side, caused profuse sweating. The application 
of an electrical stimulus or of acid on the right side 
of the tongue caused it. The condition was the 




Fig. 2. — Area of Sweating in Case XXX. 



source of a ^ood deal of discomfort, as when eating 
his meals he had to mop the side of the face every few 
minutes. The area over which the sweating oc- 
curred (not strictly ' parotid ' however) is shown in 
the diagram (Fig. 2). There was no facial paralysis 
and no disturbance of sensation. 

" Of similar cases reported in the literature, a num- 
ber of them have followed from the same cause ; 
others after injuries in the parotid region." 



CHAPTER XL 
TYPHOID AFFECTIONS OF THE THYROID GLAND. 

The presence of the typhoid bacillus in the thyroid 
gland has been affirmed by a number of authors 
(see p. 28). That the pyogenic bacteria should also 
be present would not be surprising ; but in the ten 
tabulated cases in which the thyroid. was involved, in 
only one x was the staphylococcus albus found, and 
then not alone, but mingled with Eberth's bacillus. 
In three others 2 the typhoid bacillus was found alone. 
In the last case, while there can be no question that 
the suppuration in the old goiter was due to the ty- 
phoid bacillus, it may possibly be a question whether 
the patient had really typhoid fever. The thyroid 
abscess began on the second day. No typhoid bacilli 
were found in the stools. If it was not a case of 
typhoid fever, then it would seem to be analogous 
to the cases referred to on page 43 of typhoid in- 
fection without the usual intestinal lesions of typhoid 
fever. 

It may be merely accidental, but it is at least 
noteworthy, that of the ten cases in my table, in 
four suppuration occurred in thyroids already dis- 
eased — i. e., in old goiters. This may have been a 

1 Spirig, Correspondenzbl. f. schweiz. Aerzte, Feb. 15, 1891. 

2 Colzi, Lo Sperimentale, 1891, No. 2 ; Dupraz, Arch, de Med. Exp. et 
d'Anat. Pathol., Jan. I, 1892, 76; Kummer and Tavel, Rev. de Chir., June, 
i8 9 i,p. 507. 

186 



THE THYROID GLAND. \ 87 

predisposing cause. The infection may readily 
reach the eland through the blood, even when this 
gland is normal ; but when it is in the condition of 
cystic goiter, this is still more readily conceivable. 
Colzi, in his case, attributed it to hemorrhages into 
the cystic cavities caused by die constant cough, 
and that then infection of the blood clots easily 
occurred through the blood current. In all but one 
of the ten, suppuration occurred. In seven the 
attack began in convalescence — i. e., after the third 
week ; in two as late as the seventh or eighth week. 
Five were males as against two females. Two were 
" young" — presumably, therefore, under twenty; 
two between twenty and thirty ; three were over 
thirty. Six recovered, and one, who had also an 
abscess of the spleen, died. 

Several of Liining's cases of the laryngeal com- 
plications of typhoid had also old goiters. They 
are tabulated in the next chapter and not here. 

Treatment. — When suppuration has taken place, 
the only treatment, of course, is to open the abscess 
under careful aseptic precautions if the gland be 
normal ; but if the case be one of old goiter, it may 
be better to extirpate the suppurating half, as was 
done by Kummer. This would only be done, of 
course, in convalescence. During the fever, only 
temporizing methods should be employed. 



CHAPTER XII. 
TYPHOID AFFECTIONS OF THE LARYNX. 

The larynx and the joints are the two sites of 
frequent surgical complications of typhoid upon the 
pathology of which the discovery of the bacillus of 
Eberth has had practically no influence. In Chapter 
IV I have related the results of bacteriological ex- 
amination in typhoid arthritis. In not a single case 
has the bacillus been found in the joints, nor am I 
aware of a single observation which has revealed 
its presence in the larynx. Possibly such a case 
may exist, but if so it has not been found in the 
pains-taking search of Dr. Westcott. 

The present chapter, therefore, will be little more 
than an enlargement in the way of statistics of the 
corresponding chapter in my Toner Lecture, — to 
which, in the Appendix, the reader must be referred, 
— together with-the development of such additional 
facts as the larger number of cases will furnish. 

But one attempt has been made since my lecture 
in 1876 to gather together the material needful for 
the consideration of the subject. 1 In 1876 I collected 
169 cases. In 1884 Liining, who had evidently not 
seen my lecture, collected 213 cases. Dr. West- 
cott has not collated the two series, as it would 
have been an unnecessary and tedious task. Pre- 
sumably they are very nearly identical, excepting 

1 Liining, Archiv f. klin. Chirurgie, 1884, xxx, 225. 
188 



TYPHOID AFFECTIONS OF THE LARYNX. [89 

the 14 original cases reported by Liining and the 30 
cases in excess of my first series. Dr. Westcott has, 

however, collected 38 cases since Luning's paper, 
which, with Ltining's 14 original ones, added to the 
169 of my first series, make 221. The following re- 
marks are based, therefore, upon these 221 cases. 
I shall also quote, as occasion demands, some tables 
and remarks by Liining, whose paper is not only 
very full and detailed, but of the greatest interest 
and importance both to the surgeon and the laryn- 
gologist. 

Ltining's description of the symptoms is so 
graphic, and so useful in calling attention to the un- 
expectedness and the dangers of such cases, that 
I can not do better than to quote it in full (p. 286): 

"The fact that the patient, at the time when the 
lesions in the larynx are so wide-spread that they 
ought to be recognized clinically, lies in typhoid 
apathy, and often makes no complaint of his suffer- 
ing, is a great hindrance to the clinician. All the 
more is it his duty not to allow even slight com- 
plaints, especially if they arouse even a suspicion of 
any laryngeal complication, to pass unnoticed. . . . 
In the histories will be found the oft-recurring re- 
marks, 'The patient was doing well,' or 'he was 
slightly hoarse,' ' complained slightly of dysphagia,' 
etc. . . . Physician and patient together rejoice 
over the daily progress toward convalescence ; of 
the still slight but persistent trouble in the throat 
scarcely a word is said, until all at once — an exposure 
to cold, a little walk, is then usually blamed for it — 
the hoarseness increases, and swallowing becomes 
markedly painful. The picture now quickly alters. 
Soon, often within a few hours, come dyspnea and 
suffocative attacks. Sometimes even durine the 



190 SURGERY OF TYPHOID FEVER. 

very first day the anxious scene of laryngeal steno- 
sis sets in, with stridor, inspiratory depression of the 
neck and chest wall — the unrest of despair, a struggle 
with death. The face becomes livid ; the respiration 
becomes rapid, wearisome ; the auxiliary muscles of 
respiration are all called into play ; sometimes the 
respirations are prolonged and noisy. The patient 
can find no rest ; the dyspnea even prevents the tak- 
ing of nourishment ; the expectoration of the increas- 
ing mucus becomes imperfect ; soon attacks of suf- 
focation recur. Either a tracheotomy must now be 
done immediately, or the patient, if he is weak, may 
choke to death, even in the first attack. More com- 
monly, however, the attack subsides, and a slight im- 
provement with a short sleep will ensue. Expectora- 
tion of bloody mucus, masses of pus, and, in some 
cases, even of pieces of cartilage, diminish the symp- 
toms, and show at the same time that the real cause 
of the dyspnea is not a catarrhal edema or dropsical 
swelling but a destructive ulceration, even of the 
cartilages. Often, also, there is severe fever. Thus 
pass on, it may be even days and weeks, easy 
breathing alternating with the suffocative attacks. 
The alternative is only a finally fatal attack of 
suffocation or a late palliative tracheotomy with all 
its uncertainty. ... If one will read the cases 
of death from suffocation without operation gathered 
in Table B (52 cases, 49 deaths), he will find that, 
almost without exception, suffocation occurred early 
and quickly, before either physician or patient had 
even thought of tracheotomy. 

"This is the picture in cases of perichondritis. If 
the patient is in the stage of typhoid stupor, when 
the ulceration is accompanied with acute suppura- 
tion and swelling which may lead to destruction of 
the cartilages, the initial symptoms of the threaten- 
ing danger may escape us entirely in spite of care- 
ful observation. ... In these cases the objec- 



TYPHOID AFFECTIONS OF THE LARYNX. ioi 

tive signs of laryngeal stenosis, on which we usually 
depend, are much less marked ; stridor, movements 
of the larynx, inspiratory depression, action of the 
auxiliary inspiratory muscles — in short, everything 
by which, in the healthy, we make the diagnosis 
of narrowing of the air-passages is, in the vita 
minima of the weakened patient, far less outspoken, 
and easily deceives us as to the degree of the 
danger of suffocation. The striking suffocative 
attacks, with arrest of respiration, so alarming even 
to the lay observer, are less noticeable, since the 
struggle of the patient with the mechanical obstruc- 
tion quickly fails or is quickly abandoned. The 
condition passes into a death agony, with edema of 
the lungs, without the stenosis seeming to have 
reached a threatening degree. . . . And thus one 
sees, often with astonishment, in the reports of the 
necropsies, how often the stenosis and destruction 
of the cartilages occurs, as it were, 'without even 
any symptoms. ' " 

A vivid picture like this may well give both the 
physician and the surgeon food for thought. In 
America, however, as in England, it would seem 
that cases of perichondritis are less frequent than in 
Germany. The influence of nationality was not 
alluded to in my Toner Lecture, nor was the nation- 
ality of the cases in the second series tabulated. 
Liming, however, has done so in his 199 cases from 
surgical literature, and found that of the 147 cases 
subjected to tracheotomy, 117 were from Germany 
(including Switzerland), 16 from France, and only 
8 from England. Of the 52 not tracheotomized, $j 
were French, 1 1 German, and 4 English. 

Two other points not mentioned in my former 
paper are the occurrence of emphysema and the 



192 SURGERY OF TYPHOID FEVER. 

extension of the suppuration to the mediastinum. 
Both are evidences of the gravity of the affection. 

Thus, . Wilks z records the case of a child of twelve 
who on the twelfth day developed general emphy- 
sema, due to a perforating ulcer on the posterior wall 
of the larynx. Durham 2 records a similar case in 
a boy of ten, and Chomel 3 a third in a man of twenty, 
from an ulcer which perforated the thyroid cartilage. 

In one of Liming' s cases (IX) an abscess existed 
in which no trace of the arytenoids could be found 
and the cricoid was undergoing necrosis. The an- 
terior mediastinum was infiltrated with pus. In 
another case 4 a similar abscess existed around the 
bare thyroid cartilage, and both the anterior and pos- 
terior mediastina were involved. 

Following now the order of my Toner Lecture, to 
which the reader is referred for a fuller discussion 
of each point, I will give the revised statistics of the 
two tables combined. 

The total number of cases collected is 221, of 
which at least 89, and probably many more, certainly 
involved the cartilages. 

r e. — Of 146 cases there were : 



Under fifteen, 12 

Fifteen to twenty-five, 87 

Over twenty-five, 47 

146 

showing that childhood is remarkably exempt from 
laryngeal complications. 

1 Med. Times and Gaz., 1862, ii, 276. 

2 Holmes' Syst. Surgery, 2d ed. , iv, 571. 3 These de Paris, 1877. 
4 Retslay, Ueber Perichondritis Laryngea, Berlin. Diss., 1870, No. 10. 



TYPHOID AFFECTIONS OF THE LARYNX. 193 

The corresponding" table of Liming, including his 
own 14 cases, gives : 

Age. Males. Females. Total. 

Under ten, .... 4 2 6 I 

c 
Ten to fifteen, ... 7 5 12 J 

Fifteen to twenty, .30 11 41 | 

Twenty totwenty-five, 56 12 68 J °9 

Twenty-five to thirty, 25 3 28^ 

Thirty to thirty-five, 3 2 5 I 38 

Over thirty-five, . . 4 1 5 J 

129 36 165 

The frequency from fifteen to twenty-five (109 to 
56 for all other ages) is doubtless explained by the 
greater prevalence of the fever at that age. 

Sex. — Of 148 cases in my tables there were: 

Males, 119 

Females, 29 

148 
and in Liining's table, as above, there were : 

Males, 129 

Females, 36 

165 
Site of the Stenosis. — This was : 

Supraglottic, 50 

Infraglottic, 36 

In the glottis, 18 

104 

This would seem to bear out the view of Limine 
that the arytenoids are the most frequent site of the 
perichondritis at its beginning, and that from these 
the disease extends to the cricoid. 

Date of Onset. — This is generally late and fre- 
13 



194 SURGERY OF TYPHOID FEVER. 

quently during convalescence, when the fears of the 
physician are apt to be lulled by returning health. 

First week, 7 cases. 

Second week, . ", 23 " 

Third week, 30 " 

Fourth week to two months, 83 " 

143 cases. 

Typhoid vs. Typhus Fever. — In my Toner Lec- 
ture a considerable number of cases following typhus 
fever (49) were tabulated ; in the second series only 
four. Combining the two tables there were : 

Following typhoid, 154 

Following typhus, 53 

Necrosis of the Cartilages. — This is by far the 
most common and also by far the most dangerous 
form of laryngeal affection, for of 75 cases 71 died — 
a mortality of almost 95 per cent. Of the four 
recoveries, two * recovered without operation and 
two 2 after tracheotomy. No words can be more 
eloquent than these figures. 

In the Toner Lecture I have reproduced several 
illustrations of ulceration and necrosis of the car- 
tilages following perichondritis. To these, through 
the kindness of Dr. M. H. Fussell, of Philadelphia, 3 
I am enabled to add another from a photograph 
of the specimen (Plate III). The case was one of 
perichondritis of the cricoid, and shows well the ne- 
crosed cartilage. 

1 Herard, quoted by Trousseau, Clin. Med. Syden. Soc. Trans., 2d ed., 
ii, 407 ; and Schiffers, Annales Soc. Med. Chir. de Liege, in Jour. Amer. 
Med. Assoc, 1884, 70. 

2 Tiirck and Liining, Case II, p. 223. 

3 Jour. Amer. Med. Asso., July 3, 1897. 



PLATE III. 




Dr. M. H. Fussell's case of necrosis of the cricoid cartilage (a, <?) 
after typhoid fever. 



TYPHOID AFFECTIONS OF 77 /F LARYNX. 195 

Cartilage Involved. — This was in — 

The cricoid, 43 cases. 

The arytenoids, 32 '• 

The other cartilages, 7 " 

82 cases. 

In 13 of these both the arytenoids and the cricoid 
were involved. 

In Liiningf's table the result is analogous : 

Thyroid, 2 cases. 

Thyroid and cricoid, 5 " 

Thyroid, cricoid, and arytenoids, ... 3 " 

Cricoid alone, 22 " 

Cricoid and arytenoids, 14 " 

Arytenoids alone, 9 " 

55 cases. 

As is pointed out by Liming, the broad posterior 
plate of the cricoid is the most frequent portion of 
this cartilage to be involved, and very frequently the 
disease extends from the arytenoids, or from their 
articulation with the cricoid, to the latter. 

Laryngoscopy Examination. — In my two tables 
there were only 14 such examinations made. Liming 
has gathered 18, and records the following results : 

Ulcers on the vocal chords, processus vocales, 

posterior laryngeal wall, etc., 8 

Swelling or bulging of anterior surface of pos- 
terior wall, 3 

Abscess above right vocal chord, 1 

Suppurative coating of the vocal chords, ... 2 
Subglottic symmetrical fixed red swelling 
(chorditis vocalis inferior hypertrophica (?) 
perichondritis of the cricoid (?) ), . . . .2 



196 



SURGERY OF TYPHOID FEVER. 



In all cases there was redness, swelling- edema of 
portions of the larynx, rarely of the whole larynx, 
but chiefly of the chords, epiglottis, posterior wall, 
arytenoids, and their mucous membrane. 

Prognosis. — Of 197 cases of all kinds of stenosis 
in which the result is given, 132 died and 65 recov- 
ered — a mortality of 67 per cent. Bad as is this 
showing, it is far more striking when we separate 
the cases which were tracheotomized from those 
which were not. Thus : 

Of 98 cases not operated on, 21 recovered and 
jj died — a mortality of 78.6 per cent. 

Of 99 cases operated on, 44 recovered and 55 
died — a mortality of only 55.5 per cent. 

In necrosis of the cartilages, the most dangerous 
form of stenosis, as already stated, the mortality 
was almost 95 per cent. 

To add to the eloquence of the contrast between 
78.6 per cent, without operation and 55.5 per cent, 
with operation, I may quote the following from my 
Toner Lecture : 

" When it is remembered that in two of the fatal 
cases the larynx was not opened, though trache- 
otomy was apparently performed ; and a third, in full 
recovery thirteen days after the operation, on the 
removal of the cannula was suddenly suffocated be- 
fore it could be replaced ; and in another the cannula 
became displaced in front of the trachea [that in 
over half of Liming' s 14 original cases goiter was a 
serious complication and several times was the direct 
cause of death] ; that in many, if not in most, of 
the cases the operation was deferred until the last 
possible — that is, the most unfavorable — moment ; 



TYPHOID AFFECTIONS 01< THE LARYNX. Uj7 

that many cases that might have been rescued were 
plainly allowed to die from exhaustion, or even 
from positive suffocation, by timid doctors, cases in 
which the result could not have been worse had an 
operation been performed; — the question of opera- 
tion would seem to be decided." 

All that I said twenty years ago as to the need 
of an early tracheotomy the moment that the exist- 
ence of perichondritis is recognized and suffocative 
attacks occur is only reinforced by the larger results 
from the later added cases. Delay can not be en- 
tertained for a moment, for it means a speedily fatal 
result. The terrible facts are before us. Let us 
hope that the lesson they teach will be learned. 

Intubation. — Since my former lecture intubation 
has been introduced as an operative procedure. I 
know of no case in which it has been practised, but 
it may well claim attention in the few cases to which 
it may be applicable. In perichondritis it would 
evidently be worse than useless to employ it in place 
of tracheotomy. It affords no means of escape for 
the pus, the necrotic tissue, or the fragments of the 
cartilage. But in the rare cases of simple edema, 
and in some of ulceration, its use should be con- 
sidered, though I fear that it would rarely afford the 
relief which tracheotomy gives. 

Final Results. — Liming has collected the most 
careful and complete statistics of the final results as 
to whether the cannula can be dispensed with and as 
to the value of later attempts to overcome the sten- 
osis by dilatation or other means. 

Of 60 cases which recovered after perichondritis, 
1 1 were able to dispense with the use of the cannula in 



198 SURGERY OF TYPHOID FEVER. 

periods varying from seven months to six years, but 
the other 49 were obliged to wear the cannula perma- 
nently ; some could breathe freely without it during 
the day but were obliged to wear it at night. One 
patient was known to have worn the cannula for forty 
years. 

Various means have been employed to get rid of 
the stricture, especially by dilatation with bougies and 
special cannulas. But the treatment, especially by 
dilatation, is wearisome, both to the patient and the 
surgeon, and rarely has done any good. The special 
cannulas do not seem to have been any more success- 
fully employed. In a half dozen cases attempts 
have been made to better the patient's condition by 
a total splitting of the larynx and the adaptation of 
a special cannula. These seem to have been at least 
partially successful, but the cannula had to be worn 
permanently. For the details the reader is referred 
to Liining's paper, page 329. 

To the above remarks, which interest the sur- 
geon, the physician, and the laryngologist, I may add, 
as of especial interest to the last, that a number of 
cases of paralysis of the muscles of the larynx have 
been reported. Those interested in this aspect of 
the subject will find it well described by Przedbor- 
ski. 1 Boulay and Mendel 2 have reported 17 cases, 
and Bernoud 3 reports another case. 

1 Ueber Lahmungen der Kehlkopfmuskeln beim Unterleibs und Fleck- 
typhus. Sammlung klin. Vortrage, Neue Folge, No. 182, 1897. 

2 Des Paralysies Laryngees dans la Fievre Typhoide, Rev. de Laryngol. 
et Rhinol., 1895, xv, 615. 

3 Lyon Med., March 28, 1897, p. 453. 



CHAPTER XIII. 

TYPHOID AFFECTIONS OF THE PLEURA, LUNGS, AND 
HEART. 

One of the very first regions in which the pyo- 
genic power of the typhoid bacillus was proved was 
in the pleural cavity. In 1885 Rendu and de 
Gennes, 1 and in 1887 A. Fraenkel, 2 found pure cul- 
tures of the typhoid bacillus in the pus from cases 
of purulent pleurisy. 

Dr. Westcott has gathered together in all nine 
cases. In five of them bacteriological examinations 
showed the bacillus of Eberth. 

Except one case, in which the date of onset is not 
given, every one arose after the third week, and in 
five from one to two months after the fever, thus 
illustrating again the late period of these typhoid 
sequels. 

In one 3 it arose from a pneumothorax, occurring 
on the thirty-eighth day after convalescence, both 
from the fever and from a broncho-pneumonia. In 
one case there was an abscess of the lungs, 4 in an- 
other o-anorene of the lun^ and abscess of the 
spleen, 5 and in a third 6 there was pus in the an- 
terior mediastinum. 

1 La France Med., 1885, ii, 1821. 

2 Verhandl. Sechste Kongress inner. Med., 1S87, 179. 

3 Rendu, La France Med., 1885, ii, 1809. 

4 Ramsey, Annals of Surgery, Jan., 1890, 39. 

5 Griesinger, Infectionskrankh. 

6 Barr, Liverpool Med.-Chir. Jour., 1893, xiii, 346. 

I99 



200 SURGERY OF TYPHOID FEVER. 

Only two cases died, one of abscess of the lung 
and one of uncomplicated empyema. 

The symptoms do not call for special mention, but 
the treatment does. At least three of the cases re- 
covered after puncture, including even the one with 
pus in the mediastinum. In three others incision 
and drainage, in one of which two ribs were resected, 
accomplished a cure. The fact that the patient was 
exceedingly weak led to the choice of aspiration in 
the mediastinal case just mentioned, and 70 ounces 
of pus were withdrawn. Even should aspiration 
not be followed by cure, it may give important tem- 
porary relief, especially if the amount of fluid (as in 
that case) is such as to embarrass the respiration or 
circulation, and may thus give the patient time to 
recuperate his forces for a later and more radical 
operation if that proves to be necessary. In one 
case T two aspirations were needed and it was 
observed that the typhoid bacilli from the second 
puncture were less virulent than those from the first. 

Five were males and four females ; four were 
under twenty years old and four from twenty to thirty- 
three ; all arose after the third week and two as late 
as two months from the onset of the fever. 

Heart. — There are also recorded two cases of 
purulent pericarditis 2 and one of an abscess in the 
wall of the heart. Of the former, one was found 
at the autopsy, the patient, a boy of nine, dying on 
the seventeenth day. The latter 3 was in a man of 

1 Weintraud, Berlin, klin. Wochen., 1893, xxx, 345. 

2 Zeller, La France Med., 1881 ; and Le Clerc, La France Med., 1881, 54. 

3 Driguet, quoted by Michon, Contrib. al'Etude des Suppur. dans la 
Fievre Typhoide, These de Lyon, 1890. 



THE PLEURA, LUNGS, AND HEART. 201 

thirty-six, who died on the thirtieth day, and was 
likewise found at the autopsy. 

In view of the so frequent and characteristic 
changes in the heart muscle, it is rather singular that 
rupture of the muscular fibers, hematomata, and ab- 
scess are not more frequent in the heart. Save 
this one case, they are conspicuous by their absence. 
It is to be noted, also, that the typhoid bacillus has 
been found in the muscular tissue of the heart 
itself. 1 

The treatment of a purulent pericarditis of ty- 
phoid origin would differ in no way from one arising 
from any other cause, except that the fever, if con- 
valescence be not yet fully established, would seri- 
ously diminish the chances of recovery. 

1 Chantemesse and Widal, Gaz. Hebd., March 4, 1887, 146. (See also pp. 
23 and 59, ante. ) 



CHAPTER XIV. 

TYPHOID AFFECTIONS OF THE ESOPHAGUS AND THE 

STOMACH. 

I. Stricture of the Esophagus. — In the exten- 
sive tables we have collected no cases of typhoid 
surgical affections of the esophagus other than 
"diphtheric," exudative, and ulcerative manifesta- 
tions have been met with. 

But through the kindness of Prof. Osier, of Johns 
Hopkins University, and of Dr. Frederick A. Pack- 
ard, of Philadelphia, I am enabled to publish two 
cases, which, so far as I know, are the only cases of 
the kind on record. Both of them are cases of 
stricture of the esophagus. Presumably, they fol- 
lowed upon typhoid ulcers resulting in cicatricial 
contraction. 

The symptoms and treatment are the same as is 
proper in similar stenosis from other causes, and call 
for no special comment. 

Case XXXI (Osier).— " Mrs. Mary M. J., age 
thirty-six, Judith, Union Co., N. C, was admitted 
September 26, 1897, complaining of inability to swal- 
low solid food. 

" There was nothing in her family history of any 
moment. 

" Personal History. — She was healthy as a girl ; 
married at twenty-one ; has had no children. She 
has suffered at times from dyspepsia during the past 
six or seven years. 

202 



THE ESOPHAGUS AND THE STOMACH. 203 

" Her present trouble began in January, 1896. Dr. 
Nance, of Unionville, N. C, writes as follows : ' My 
first visit to Mrs. J. was January 27, 1896, and 
from this time until about the end of March she was 
ill with typhoid fever. The actual time in bed was 
seven weeks. The original attack lasted three 
weeks, during which time she had no delirium. 
About the end of the third week she had hemorrhage 
from the bowels, and passed about a pint of blood. 
Then she had a relapse, which was much more 
severe than the original attack, in which she had 
delirium of a wandering nature. At about the third 
week of the relapse she developed a considerable 
gastritis, with accompanying vomiting, which con- 
tinued, on and off, for ten or fifteen clays. There 
was at no time any hemorrhage from the mouth or 
blood in the vomit. When she first came out of her 
delirium, about the end of the sixth week, she com- 
plained of some difficulty in swallowing ; at first 
slight, but with a steady increase as her general 
condition improved, until, at the end of the eighth 
week, she was nearly in the condition she was when 
I sent her to the hospital.' 

" According to the patient's statement, she has not 
been able to swallow solid food since convalescence. 
The pain, she says, was severe at first ; she located 
it at a spot below the outer third of the right clavi- 
cle, but after the passage of the stomach-tube it is 
relieved, and is lower down, at the right costal bor- 
der. At times she can swallow water or milk with- 
out pain ; at other times the pain is severe. She 
has no vomiting, except the regurgitation of food 
which she tries to swallow. She has never brought 
up any blood. On trying to swallow solid food, it 
goes, as she expresses it, to the " bottom of the 
swallow," and then comes back aeain. She can hold 
it sometimes as lone as five minutes. Ever since 
her convalescence she has been living on milk and 



204 SURGERY OF TYPHOID FEVER. 

thin soup. She feels well, and has no pain except 
when she tries to swallow. In drinking milk, she 
takes it very slowly and only a little at a time. She 
says that, at one time there was complete stoppage, 
due to coffee-grounds, and she could not swallow 
anything for two or three days. 

" Condition on Admission. — Patient is a thin, dark 
woman. The lips are of fairly good color, the 
tongue has a brownish fur, and the breath is foul. 
In the physical examination there is nothing of 
special moment. 

" On the 28th the stomach-tube was passed easily 
for 34 cm., and then an obstruction was met, which 
could not be overcome by any of the ordinary bou- 
gies. 

" On the 29th I passed a filiform bougie not quite 
two mm. in diameter. It was quite impossible to pass 
the smallest olive-tipped probang, measuring be- 
tween five and six millimeters. 

" On the 30th it was found impossible to engage a 
three mm. bougie in the stricture, which stopped it 
exactly 34 cm. from the teeth. From this date on, 
daily attempts were made by Dr. Mitchell, the house 
physician, to pass the larger bougies, and it was not 
until the 13th that two filiform bougies were passed 
together. The next day they were passed again, 
and immediately afterward the smallest-sized olive- 
tipped probang (No. 18, French). The obstruction 
could be distinctly felt, and the probang seemed to 
pass over a sharp edge. From this time on the 
stricture was easily dilated, until, on the first of No- 
vember, the olive-tipped bougies Nos. 31 and 2>?> 
were passed, and for the first time since her typhoid 
fever she was able to swallow some bread and meat." 

Case XXXII (Packard).— "A. B., white, male, 
age thirty-five years, was admitted to the Philadel- 
phia Hospital, October 21, 1897, suffering fro m great 
weakness and emaciation. He had been treated by 



THE ESOPHAGUS AND THE STOMACH. 205 

Dr. Ray E. Whelan in the Youngstown (Ohio) 
Hospital for typhoid fever, twelve weeks before his 
admission to my ward. On writing to Dr. Whelan, 
I received a very courteous note from him giving me 
the following facts: The patient went through a 
typical attack of typhoid fever, during which he had 
hemorrhages from the bowels and from the stomach 
or esophagus. He was given sulpho-carbolate of 
zinc in five-grain capsules, but these had to be dis- 
continued owing to the difficulty experienced in 
swallowing them. No other trouble with swallowing 
was noted while the patient was on liquid diet. Be- 
fore his discharge from the Youngstown Hospital 
bougies were twice passed, and two strictures were 
encountered, one of which was impassable. 

" On his admission to the Philadelphia Hospital, the 
following history was elicited : The family history was 
entirely negative as regards his present trouble. He 
had malaria a year ago. Denied absolutely venereal 
history, traumatism, and the swallowing of hot or 
corrosive liquids, and showed no sign of hysterical 
tendency. He uses alcohol and tobacco to excess. 

"He was very much emaciated, pale, and weak. 
The tongue was lightly coated, the tonsils a little 
enlarged, the pharynx very red. Physical examina- 
tion showed absolutely no other pathological change 
except in the esophagus. The swallowing time was 
from twenty-five to thirty-five seconds. A bougie 
(1.5 cm. in diameter) was introduced and met with 
an obstruction about 14 cm. from the teeth. On the 
next day a smaller bougie (7.5 mm.) passed through 
this stricture with a little persuasion, but at a point 
24 cm. from the teeth met with an impassable ob- 
struction. This lower stricture allows now of the 
engagement of the tip of an esophageal bougie with 
spindle-shaped bulb, the greatest diameter of the 
bulb beincr five mm. He can swallow milk with some 
difficulty, at times for several hours being unable to 



206 SURGERY OF TYPHOID FEVER. 

get this through. The passage of the bougie seems 
to assist swallowing for a time ; partly, no doubt, 
from the fact that large quantities of mucus are ex- 
pelled after its withdrawal. The patient is still under 
treatment (Nov. 25, 1897)." 

II. Ulceration Causing Hemorrhage or Per- 
foration of the Stomach. — The only surgical com- 
plication I am aware of is hemorrhage from the stom- 
ach; perforation is also a possibility; — both due to 
typhoid ulceration. Pepper 1 refers to such cases, and 
says : " Typical typhoid ulcers have very occasionally 
been found in the stomach. They produce no charac- 
teristic symptoms, but have been known to cause hem- 
orrhage or perforation." No case of actual perforation 
has come to my knowledge. Should such a com- 
plication arise, the only hope of the patient, as in 
perforation of the gall-bladder (Chap. XVI) or of 
the intestine (Chap. XV), is in immediate abdominal 
section. It is a desperate remedy, it is true, but the 
only alternative is absolutely certain death. The 
treatment of the perforation is the same as in other 
perforations, by inversion of the margins by Lem- 
bert's or other suture, provided the circumstances 
admit of such interference. 

While no case of absolute perforation has been 
found, Soltau Fen wick, 2 records a case to which Dr. 
Packard has kindly drawn my attention, in which 
typhoid ulcers very nearly perforated (p. 286), and 
a second (p. 290, Case 10), in which actual per- 
foration presumably took place, but peritonitis was 
prevented by the adhesions to the liver. It is to be 

1 Amer. Text Book of Med., i, 91 ; ii, 769. 

2 Disorders of Digestion in Infancy and Childhood, 1897, p. 286. 



THE ESOPHAGUS AND THE STOMACH. 



107 



noted that the cause of her death was a sudden and 
severe hemorrhage from one of the ulcers. 

Case XXXIII (Fenwick). — " Figure 3 represents 
a drawing of a stomach taken from a girl, eight years 
of age, who succumbed during the third week of en- 
teric fever. Four well-defined ulcers were found in 
the pyloric region, one of which presented a loosely 




Fig. 3. — Drawing of the pyloric end of the stomach in a case of enteric 
fever: a, Acute perforating ulcers with clean bases; b, an ulcer with ad- 
herent slough (W. Soltau Fenwick). 



adherent slough. The ecl^es of the ulcers were 
sharply defined and somewhat undermined, while 
their bases were situated in the submucous and mus- 
cular coats of the organ. On microscopic examina- 
tion the lymphoid tissue of the stomach was found to 
be enormously increased, and the supposition that 



208 SURGERY OF TYPHOID FEVER. 

the ulcers originated in disease of the solitary glands 
was confirmed by the appearances of the smallest 
one. From these facts it would appear that, under 
certain circumstances, disease of the solitary gastric 
glands may give rise to a form of perforating ulcer 
of the stomach which closely resembles the idiopathic 
type of the disease." 

By the kind permission of Dr. Fenwick and the 

publisher, the figure is reproduced (Fig. 3). 

Case XXXI V (Fenwick). — "A girl, thirteen years 
old, was admitted into the hospital with the symptoms 
of typhoid fever of eight days' duration. Vomiting 
occurred once or twice, but there was no complaint 
of epigastric pain. At the end of the fourth week 
of the disease, when the temperature had begun to 
decline, the patient was suddenly seized with severe 
hematemesis, after which she became unconscious 
and died. At the necropsy the anterior wall of the 
stomach was found to be adherent to the under sur- 
face of the liver. Scattered over the inner surface 
of the stomach there were numerous sharply defined 
ulcers, the largest of which was about the size of a 
florin. The edges were thin and undermined and 
the base formed by the muscular or peritoneal coat. 
In the first part of the duodenum there was an ulcer 
of a similar character, while the whole of the intes- 
tine, from the jejunum to the rectum, was riddled 
with typical typhoid ulcers." 

Hemorrhage from such ulceration without perfora- 
tion is rare. 

Hematemesis in Typhoid Fever. — Eichhorst 
mentions having once seen bleeding from the 
stomach in typhus, and says that Weiss has seen 
fatal hemorrhage. (Cf. Case XXXIV.) There is 
no reference in the fifth edition (1897) of Eichhorst's 



THE ESOPHAGUS AND THE STOMACH. 209 

Handbuch der Speciellen Pathologie and Therapie, 

in the section on the Stomach, under the anatomical 
lesions, to hemorrhage or perforation. Under the 
complications hematemesis is mentioned, and the 
possibility of typhoid ulcer occurring in the stomach 
is considered. 

Through the kindness of Prof. Osier, I am per- 
mitted to publish the following cases of hematemesis 
in typhoid fever. 

It is probable that, in general, expectant rather 
than operative treatment would be the wisest course. 
That two of the three cases recovered without 
operation would seem to vindicate this view. 

The same may be said of hemorrhage from the 
bowels, which, as it is so closely allied to the topic 
under discussion, may be considered here, though 
not belonging to the subject of this chapter. It 
would be extremely difficult to locate the exact 
point of hemorrhage in the bowel. Even at the 
necropsy, when the bowel is laid open it is not 
always easy to find the source of the hemorrhage. 
How much more difficult it would be to find it 
when the bowel is closed. The various, and, it may 
be, the numerous, swollen Peyer's patches would be 
perceptible to the touch ; but how could the surgeon 
determine which was the one from which the bleed- 
ing came? (See Plate IV, Fig. 1.) Resection 
of all the implicated bowel would not be considered, 
it seems to me, for a moment; and the large num- 
ber of recoveries, even after severe hemorrhages 
from the bowels, would warrant our concluding that 
the expectant and symptomatic medical treatment is 
certainly the best. 
14 



2IO SURGERY OF TYPHOID FEVER. 

Case XXXV{Os\zy).— " John M., age forty (hos- 
pital No. 1683), was admitted August 21, 1890, with 
a history of illness of some weeks' duration. The 
chief symptoms were headache and fever. The blood 
examination was negative. There was a very definite 
rose-colored eruption. The temperature was never 
high, not rising above 103 . On the 27th he vomited, 
and in one of the attacks he brought up a dark 
greenish-brown fluid containing red blood-corpuscles 
in a condition of disintegration and a clot of blood 
about three by two cm. in diameter. On the 29th, 
30th, and 3 1 st the stools were very dark in color, and 
evidently contained blood, and several times he 
vomited very dark material. He became very anemic, 
but made a good recovery." 

Case XXXVI (Osier). — " Alberta C, colored, age 
twenty (hospital No. 10,131), admitted June 14, 
1894. This patient was admitted in the third week 
of the disease. On that afternoon she had had 
a hemorrhage from the bowels. She was bleeding 
quite freely on admission. Between 6 and 8 p.m. she 
had five large stools of almost pure blood with clots. 
Throughout the following day she was extremely 
feeble ; temperature was normal ; patient was deli- 
rious. On June 16th there was no further bleeding 
from the bowels. Toward evening the patient was 
delirious, and her condition was very bad. At 8.15 
p.m. she vomited 100 c.c. of dark bloody fluid, which 
contained blood coloring-matter and red blood-cor- 
puscles. She sank, and died that evening." 

Case XXXVII (Osier).— " Dr. H., age twenty- 
two (hospital No. 14,933), admitted January 9, 1896 
He had a very severe attack, with persistent fever, 
which resisted the baths. These, though given from 
the outset, did not check the onset of quite active de- 
lirium. 

" On January 25th, about the eighteenth day of the 
disease, the abdomen was a good deal distended, 



THE ESOPHAGUS AND THE STOMACH. 211 

there was moderate diarrhea, and less delirium. I [e 
seemed to be doing- very well. He had had no 
special gastric symptoms. In the afternoon he quite 
suddenly sprang up in bed and vomited a quantity of 
dark blood. The amount was difficult to estimate, as 
it went all over the bed linen. Part of it was collected, 
and Dr. Parsons estimated the amount to be about 
200 c.c. It contained much debris and red blood- 
corpuscles. The staining on the sheets was quite 
red. 

"On the 26th the temperature was between 103 
and 104 , and in the afternoon at 3.05 he vomited be- 
tween 200 and 300 c.c. of almost pure, bright red 
blood. The pulse became more rapid, but these two 
hemorrhages did not appear to have any injurious 
influence. His temperature gradually fell, and was 
normal on the 31st. He made an uninterrupted 
recovery after a most severe attack." 

Just as this manuscript is passing through the 
press I have received from Prof. William Osier, of 
Johns Hopkins University, under date of January 
nth, the following: 

Glossitis. — Another very interesting and rare 
complication of typhoid occurred last week in a 
convalescent ; namely, acute glossitis. The man 
had an ordinary attack, no fever for ten days ; 
went out on December 31st. He returned three 
days later with his mouth open and the tongue 
enormously swollen and very tender. I thought at 
first it was going to suppurate, but in the course 
of three or four days it subsided. 



CHAPTER XV. 
INTESTINAL PERFORATION IN TYPHOID FEVER. 

The frequent occurrence of perforation of the 
bowel in typhoid fever has long been recognized, 
but it was not until Leyden, 1 in 1884, first proposed 
to treat the resulting peritonitis by operative meas- 
ures, which he believed to be " a most fruitful field 
for investigation," that surgeons seriously considered 
the question of its possible success. In the same 
year appeared an article by Mikulicz, 2 in which he 
reported three cases of peritonitis which he had 
treated surgically ; one of them being, it is fairly cer- 
tain, a case of perforation in typhoid fever. In 1886 
Prof. James C. Wilson 3 was the first writer in Eng- 
lish to suggest that operative' measures should be 
instituted in typhoid perforation. I had the pleasure 
of being associated with Prof. Wilson in this case, 
and we discussed most seriously the question of 
operation, but from day to day decided against its 
expediency at that time, and the patient happily re- 
covered without operation. 

The first operation in a positively known case of 
typhoid was reported by Liicke, 4 and in the same 
year Bontecou 5 operated on another patient. 

1 Deutsch. med. Wochen., 1884, 258. 

2 Samml. klin. Vortrage, No. 262. 

3 Phila. Med. Times, Dec. II, 1886. 

4 Deutsch. Zeit. f. Chin, No. 25, Heft 1. 

5 Jour. Am. Med. Assoc, 1888, No. 10, p. 106. 

212 



INTESTINAL PERFOR. I '/VOX. 2 1 3 

Before taking up the question of operation, how- 
ever, there are a few points in reference to perfora- 
tion Itself which will be of value for us to consider. 
I shall take the figures and some of the tables from 
the admirable paper of Fitz, 1 in which, with his usual 
thoroughness and accuracy, he has collected a large 
number of statistics from tables of 4680 cases of 
typhoid. 

The frequency of typhoid perforation is estimated 
variously. Thus, Schulz 2 found that peritonitis from 
intestinal perforation took place in 1.2 per cent, of 
3686 Hamburg cases in 1886-87. This accords with 
the statement of Liebermeister, 3 who found intestinal 
perforation in 1.3 per cent, of over 2000 Basle cases 
between 1865 an< ^ 1872. Holscher 4 found perfora- 
tion in 6 per cent, of 2000 cases. Murchison 5 found 
its frequency was 11.38 per cent, in 1721 cases. In 
the 4680 cases tabulated by Fitz, the mortality from 
perforation was 6.58 per cent., which may be ac- 
cepted, therefore, as fairly representing its fre- 
quency. 

In 444 cases (Fitz), it occurred among men in 71 
per cent, of the cases, and among women in 29 per 
cent. Certainly, it is much more frequent among 
men than among women ; for what reason we do 
not know. In children it is very rare. 

1 Trans. Assoc, of Am. Physicians, 1S91, vi, p. 200. 

2 Centralbl. f. all. path. Anat., 1S91, ii, 2S9. 

3 Ziemssen's Handb. spec. Path. u. Therap., 1S74, ii, 1, 161. 
* Munch, med. Wochen., 1891 , xxxviii, 64. 

5 Continued Fevers, second edition, 1S73, 5^6. 



214 



SURGERY OF TYPHOID FEVER. 



Age at Which Perforation Occurs. — Fitz's table is 
as follows : 

Age. 
One to ten years, . . 
Ten to twenty years, . 
Twenty to thirty years, 
Thirty to forty years, 
Forty to fifty years, . 
Fifty to sixty years, . 
Sixty to seventy years, 

192 

Date of Occurrence of the Perforation. — Fitz's 
table is, again, as follows : 



Cases. 


Per Cent 


• 7 


3-6 


. 46 


23.8 


• 77 


39-8 


• 45 


2 3-3 


• 14 


7.2 


. 2 


1.0 


. 1 


°-5 



Week. Cases. 

First, 4 

Second, 32 

Third, 48 

Fourth, 42 

Fifth, 27 

Sixth, 21 

Seventh, 5 

Eighth, 3 

Ninth, 2 

Tenth, 4 

Eleventh, 3 

Twelfth, 1 

Sixteenth, 1 



Per Cent. 

16.5 
24.8 



193 



The Seat of the Perforation (Fitz). — In 167 cases. 



Seat. Cases. 

Ileum, 136 

Large intestine, 20 

Vermiform appendix, .... 5 
Meckel's diverticulum, ... 4 
Jejunum, 2 



Per Cent. 
81.4 
12.9 



INTESTINAL PERFORA TION. 2 1 5 

Hawkins, 1 in 72 cases of perforation, found 61 in 
the ileum, 3 in the cecum, 3 in the appendix, and 5 
in the colon. Adding- 5 cases of perforation of the 
colon from other sources, of the ten cases there were 
2 in the ascending, 1 in the transverse, and 7 in the 
descending colon — of which 5 were in the sigmoid 
flexure. If, therefore, no perforation be found in 
the ileum, cecum, or appendix, the next most likely 
point would be the sigmoid flexure. 

In one curious case reported by Haegler, 2 in a 
woman, aged thirty-five, who had a hernia as large as 
a child's head (the result of a celiotomy performed 
some years before), on the sixth day after her admis- 
sion a perforation occurred through the wall of the 
hernia, followed by a fecal fistula, eventually ^ of 
an inch wide and two inches long. Within ten days 
three other fistulse formed near the first one. In 
spite of her excessive emaciation and a bedsore 
over the sacrum she insisted upon going home, 
where she finally recovered and the fistulae spontane- 
ously closed. The explanation given by the author is 
that a loop of intestine in the hernia became the seat 
of typhoid ulceration, leading finally to perforation. 

Nitmber of Perfo7 r ations. — Fortunately both for 
the patient and the surgeon, if interference is de- 
cided upon, the perforation is almost uniformly 
single, but Fitz reports that there were in 167 cases : 
2 perforations in 19 cases 

5 

4 

Several " 

25 to 30 

1 Lancet, 1893, ii, 245. 2 N. Y. Med. Jour., July 17, 1897, 93, fr 

Correspondenzbl. f. schweiz. Aerzte, 1896, No. 17. 



in 


3 " 


in 


1 case 


in 


4 cases 


in 


2 " 



216 



SURGERY OF TYPHOID FEVER. 



Lebert 1 and Hoffman 2 report the last two cases. 

Character of the Perforation. — If the perforation 
result from the ulceration of a solitary follicle, it is 
apt to be small and round (Plate IV, Fig. 2 ; Plate V, 
Fig. 2). If it result from the perforation of a patch 
of Peyer, it may be oval or round, and will be much 
larger than in the former case (Plate IV, Fig. 1 ; and 
Plate V, Fig. 1), and may even involve a half of 
the circumference of the bowel (Plate IV, Fig. 1). 
Sometimes shreds of tissue will be left partially 
closing the opening (Plate V, Fig. 1) ; at others the 
opening is total and clean cut. Not uncommonly 
there is a tolerably wide area around the ulcer in 
which the intestinal wall has been greatly thinned 
(Plate IV, Fig. 2 ; Plate V, Fig. 2). This is of great 
importance from an operative point of view (vide 
infra)? 

Duration of Life after Perforation. — Of 134 cases 
(Fitz) : 

D 



ied on the first day, . . . 


. 37.3 per cent 


" on the second day, . . 


• 2 9-5 " 


" in the first week, . . . 


• • 83-4 " 


" in the second week, . . 


. . 9 cases 


u in the third week, . . 


• 4 " 


" in thirty days, .... 


. 1 case 


" in thirty-eight days, . . 


. 1 " 



We should naturally expect that perforation would 
be more frequent in proportion to the gravity of the 

1 Ueber d. Typhus- u. d. Typh.-Epid. d. Jahr. 1857 ; Friedrich, Die Para- 
centese d. Unterleibs b. Darmperf. im Abdominaltyph., 1867. 

2 Untersuch. u. d. path. anat. Verand. d. Organe beim abdominaltyph., 
1869. 

3 Plates IV and V are from specimens in the Museum of the Pennsylvania 
Hospital, which I was kindly allowed to have photographed. 






PLATE IV. 




Fig. I. — Two intestinal perforations in typhoid fever. A third small per- 
foration existed just above the large one. Resection of the bowel would have 
been the only possible mode of treating the large perforation, as lateral closure 
would have produced great stenosis. Observe the numerous areas of thinning 
of the wall of the bowel from ulceration. (Museum of the Pennsylvania 
Hospital.) 



i 


- v '^v-^u***- . . .^w 


I 






fmmSKw^ww Zr — **7 


!> 


T^B8BB*tt*Lz^^KF~~''J^^--, 




j^^^^L^L^ ^^^^^^^^^P ' *^^^^^ Z^^^l 




mk L—^dfm 




-i!^^r^^!^?2^^BHH 




■-j^rf-^S^--*^^ 


.*-£.. 





Fig. 2. — Intestinal perforation in typhoid fever. Observe the thinned 
wall around the perforation. (Museum of the Pennsylvania Hospital.) 



PLATE V. 




Fig. I. — Intestinal perforation in typhoid fever. Observe the threads of 
tissue obstructing the opening. (Museum of the Pennsylvania Hospital.) 




:. — Intestinal perforation in typhoid fever. Observe the wide-spread 
thinning of the intestinal wall around the actual perforation. (Museum of 
the Pennsylvania Hospital.) 



INTESTINAL PERFORA T/ON. 2 1 ; 

disease, but Fitz state's that there is no definite rela- 
tion between the two. In about one-fourth of nearly 
2000 cases the course of the disease was distinctly 
stated to be mild. Of walking typhoid there were 

14 cases, and several cases have been reported in 
which the perforation was only found at the necropsy. 

Diagnosis of Perforation. — Of 80 cases in which a 
record was made of the symptoms, it was found 
(Fitz) that in 56 cases the onset was sudden, in 

15 the symptoms were gradual or latent, while in 
five there were no symptoms whatever pointing 
to the perforation. Armstrong, in a personal 
letter, says "In none of my cases was the occur- 
rence of perforation indicated by those well-marked, 
striking- symptoms so generally mentioned in text- 
books." 

In addition to this, it must be remembered that 
fatal peritonitis may arise during typhoid fever with 
out any perforation being discovered, at operation 
or even by a necropsy. Herringham and Bowlby x 
record a striking case in which the symptoms pointed 
plainly to perforation, yet the operation revealed 
only scybala in the colon. The patient recovered. 

There are also other causes for typhoid peritonitis 
than typhoid perforation, as I have shown in the 
chapters on Abscess (from rupture of the mesenteric 
glands, and abscesses of the abdominal wall), on the 
Spleen, and especially in the chapter on the Liver 
and Gall-bladder, from perforating ulcers of the gall- 
bladder. Fitz has well said (p. 207), "Since per- 
foration of the intestine in typhoid fever may take 
place without any suggestive symptoms, and since 

1 Brit. Med. Jour., 1S07, l - 2< ^5- 



2l8 SURGERY OF TYPHOID FEVER. 

suggestive — even so-called characteristic — -symptoms 
may occur without any perforation having taken 
place, it must be admitted that recovery from such 
symptoms is not satisfactory evidence of recovery 
from perforation." But there are certainly a number 
of cases on record in which perforation could not be 
doubted which have recovered. Murchison, how- 
ever, estimates that the mortality of typhoid perfora- 
tions in general is about 90 per cent., and in those in 
which general peritonitis supervenes after such per- 
forations it is 95 per cent. 

The ordinary symptoms which indicate perforation 
are, especially, sudden and severe abdominal pain, 
usually in the neighborhood of the right iliac fossa or 
the hypogastrium, collapse, nausea and vomiting, 
with occasionally a marked fall of temperature. It 
would be supposed that in consequence of the per- 
foration the intestinal gases would escape, and this 
would be followed by disappearance of the hepatic 
dulness ; but this is only rarely reported. 

One very important symptom, which has been ob- 
served only of late, is the presence or absence of leu- 
cocytosis. According to Thayer, 1 there is no increase 
in the proportion of the white blood-corpuscles during 
the fever, but rather a slight diminution in their num- 
ber, which gradually diminishes until convalescence. 
During the fever, the number may fall even below 
2000, and sometimes below 1000, per cubic centi- 
meter. The lowest count seems to be about the end 
of the third week. Sometimes the white blood-cells 
increased markedly in number (leucocytosis) with the 
fever, even without any complication. Four cases 

1 Johns Hopkins Bulletin, iv, p. 83. 



INTESTINAL PERFOR. I TION. 2Uj 

were observed by Cabot in which the count was over 
1 1,000, and ran as high even as 17,700 without any 
other than the typical typhoid lesions. But the effect 
of complications is very marked and undoubted. I 
quote the following- examples in seven cases, two of 
typhoid perforation, from Cabot's admirable book ' : 

Perforation. . Case I. — (a) Five days before perforation, 

8300. 
(<£) At time of perforation, 24,000. 
Case II. — At time of perforation, 18,500. 

Phlebitis. . . Case I. — (a) Two clays before onset, 6400. 

(/;) At time of onset, 12,900. 
(V) One week later, 10,100. 
Case II. — (a) One week before onset, 4800. 
(<£) At time of onset, 16,200. 

Otitis Media. . Case I. — (a) At entrance, 5300. 

(Jf) Mastoid abscess, 16,400. 
Case II. — (a) At entrance, 8400. 

(^) Two weeks later, after opening 
drum membrane (sero-puru- 
lent discharge), 11,200. 
Case III. — (0) At entrance, 7320. 
(^) Otitis, 14,000. 

In addition to this he states that " a freely discharg- 
ing otitis soon ceases to cause leucocytosis — e.g., 
a case of serous otitis media seven days after punc- 
ture, but still freely discharging, showed but 5320 
white cells a cubic centimeter. An abscess of the 
buttock raised the count from 8000 to 11,200, and 
a hemorrhage from 8000 to 11,300." General bron- 
chitis and cystitis had usually no such effect. In two 
cases simulating otitis, with a normal blood count, the 
trouble turned out to be functional. 



Clinical Examination of the Blood, 1897. 



220 SURGERY OF TYPHOID FEVER. 

It is to be noted, however, that he adds: "It occa- 
sionally happens in very exhausted patients that 
complications fail to produce any leucocytosis, the 
patient-^as in some fatal cases of pneumonia or puru- 
lent peritonitis — being unable to react against the in- 
fection These cases, however, are ex- 
ceptional." In any case of doubt, therefore, if 
time allows, a blood count should be made in order 
to assist us in the diagnosis. 

The result of intestinal perforation is, in a few 
cases, a localized abscess similar to the localized 
abscess which follows a perforative appendicitis; 
but, in unfortunate contrast with perforative appen- 
dicitis, in the majority of cases no such agglutination 
of the intestine occurs, and, therefore, a generalized 
suppurative peritonitis follows speedily upon the 
perforation. This is very natural, since the intestinal 
contents are more than usually infective, both from 
the colon bacillus and from the typhoid bacillus as 
well as the ordinary pyogenic bacteria. If the per- 
forations are multiple, the peritonitis is, of course, so 
much the more certain to become general. Ordin- 

<z> 

arily, the typhoid bacilli have not been found in the 
peritoneum following perforation. Possibly, as sug- 
gested by Finney, they have been " overgrown and 
destroyed by their more active and vigorous com- 
panions, the streptococcus pyogenes and the bacillus 
coli communis." There is but a single instance, so far 
as I know, of a bacteriological examination of the 
contents of the peritoneum in typhoid perforation. 
Finney, 1 in his three cases, made cover slides and 
cultures which showed pure colon bacilli. 

1 Annals of Surg., 1897, xxv, 233. 



INTESTINAL PERFORATION. 22 1 

The dangers of surgical interference are unques- 
tionably very great. They can scarcely be stated 
better than in the frequently quoted words of 
Wilson, written over eleven years ago : ' 

"Granted that the chances of a successful issue 
are heavily against you ; that the patient is in the 
midst or at the end of a long sickness ; that his 
tissues are in the worst state to stand the injuries 
from the knife ; that the lesions of the gut may be 
very extensive ; that the vital forces are at the lowest 
ebb; — no one has yet hesitated to perform a trache- 
otomy in the laryngeal complications of enteric fever, 
which require it to save life for these reasons. The 
operative treatment of purulent peritonitis has been 
performed many times successfully by the gynecolo- 
gist in conditions less promising. In point of fact, 
the objections that may be urged against laparotomy 
in intestinal perforation in enteric fever are no more 
forcible than those which would have been made use 
of at first against the same operation in gunshot 
wounds of the abdomen. Unfortunately, this ques- 
tion is not to be settled by experiments upon animals. 
The investigation must be made upon the human 
subject, where courage to perform it will come from 
the knowledge that the only alternative is the 
patient's death." 

Commenting on the statement of Fitz, that "the 
similarity of the symptoms of perforation of the bowel 
and those of the appendix is striking. 
The symptoms are not merely similar ; they are 
actually identical, even to the usual localization of the 

1 Phila. Med. Times, 1 886, vol. xvii, 177. 



222 SURGERY OF TYPHOID FEVER. 

consequent peritonitis in the right iliac fossa," Abbe 1 
says : " This lucid statement by Fitz must appeal to 
every observer of appendicitis cases as true to the 
letter. Why one class of cases should be left to 
die while we operate on all appendicitis cases, 
when perforation can be recognized [except, I am 
sure he would say, when the patient is past hope] 
does not appear." 

But, after all, the appeal must be to the facts 
in the case. This is the final arbiter. When 
once physicians are not only on the alert to ob- 
serve the symptoms of perforation, but when the 
knowledge that perforation of the bowel can be 
remedied by surgical means has permeated the pro- 
fession, so that the instant that perforation takes 
place the surgeon will be called upon, and, if the 
case be suitable, will operate, we shall find unques- 
tionably a much larger percentage of cures than have 
thus far been reported. But even at present we 
have a reasonably large number from which to draw 
conclusions. In the table appended to this chapter 
Dr. Westcott has collected 83 well-authenticated 
cases. This gives, as a general result, 16 recoveries, 2 
or 19.36 per cent, of cures and 80.64 per cent, of 
deaths. When this is contrasted with Murchison's 
unchallenged figures of 90 to 95 per cent, of deaths 
after perforation without operation, we may well take 
courage for the future. 

If we analyze the recoveries according to age, the 
result is somewhat of a surprise. 

1 N. Y. Med. Record, Jan. 5, 1895, p. 1. 

2 Cases I, 13, 15, 25, 26, 28, 31, 40, 41, 45, 46, 47, 48, 61, 64, 68. 



INTESTINAL PERFORATION, 223 

Under fifteen years of age there were 5 cases and 
2 recoveries, or 40 per cent, of recover! 

In one of these (Case 40) resection of the intes- 
tine was done. 
If we include (Chap. XVI, Table II) one case of 
perforation of the gall-bladder with recover)-, 
the number of cases of perforation from both 
causes is 6, with 3 recoveries, or 50 per cent. 
From fifteen to twenty-five years of age there 
were 23 cases and 3 recoveries, or 13 per cent, 
of recoveries. 

From twenty-six to thirty-five years of age there 
were 24 cases and 5 recoveries, or 20.8 per cent, 
of recoveries. 

If we include two cases of perforation of the 
gall-bladder with recovery (Table II), the 
number of cases is 26, with 7 recoveries, or 
26.9 per cent. 
Over thirty-five years of age there were 1 1 cases, 
with 5 recoveries, or 45.5 per cent, of recoveries. 
If we include one fatal case of perforation of the 
gall-bladder (Table II), the number of cases 
is 12, with 5 recoveries, or 41.7 percent. 

This discloses the fact that, so far as the present 
figures go, operations for perforation of the intestine 
are more fatal between sixteen and thirty-five than 
under fifteen or over thirty-five. 

In Table I the following cases which have appear- 
ed in some former tables have not been included 
for the following reasons : 

1. Escher's, 1 since it seems more likely a case of 

1 Wien. med. Wochen., 1887, No. 19, 607. 



224 SURGERY OF TYPHOID FEVER. 

appendicitis. It is admitted by Finney into his table, 
though expressly excluded in the text. 

2. Greig Smith's. 1 This is stricken out, not only 
because the diagnosis was doubtful and no post-mor- 
tem examination verified the fact, but because Smith 
himself, in his fifth edition, omits it in his chapter on 
typhoid perforation. 

3. Taylor's, 2 since the diagnosis is extremely 
doubtful. 

4. Price's second case, 3 since, though there was a 
large amount of filthy contents with fecal odor, the 
case was more likely tubercular than typhoid, and 
the report of the case is unfortunately exceedingly 
meager. 

5. The case of 111, since a personal letter from 
Dr. Ill assures me that it was not a case of typhoid 
perforation. 

6. L. S. McMurtry's case 4 is rejected, since he 
writes me that it was a case of appendicitis. 

7. A case attributed to Lejars by Monod and 
Vanverts, as it was not one of typhoid. 

8. The case of Steel, 5 as it seems to have been a 
case of appendicitis at the outset of the fever, and not 
as a result of perforation during or after the fever. 

Some other cases which have been disputed are 
admitted, as it seems to me that the evidence is suffi- 
ciently clear to do so — namely: 

1. The case of Mikulicz, No. 1 in the table. This is 
also admitted by Finney and by Monod and Vanverts. 6 

1 Abdominal Surgery, 3d ed., 1890, 751. 2 Lancet, 1890, i, 961. 

3 Med. and Surg. Reporter, Nov. 7, 1896, 577. 

4 Price refers to it in his paper. 

5 Brit. Med. Jour., 1897, i, 13. 6 Rev. de Chir., 1897, 169. 



IN 7 ES 7 'IN A L 1 *ER 1'ORA WON. 225 

2. The cases of Hahn, Nos. 9 and 10, since the 
statement is direct and positive, though for any other 
purpose than the fatal result they are of no value. 

3. The case of Netschajew and Trojanow, No. 26. 
Though the case is somewhat doubtful, yet the bur- 
den of proof seems to be in its favor, and it is ad- 
mitted by both Finney and by Monod and Vanverts. 

4. The case of Dandridge, No. 28, though the 
perforation was not found, yet gas and stinking pus 
were found free in the belly. This is also admitted 
by Finney. 

5. The case of Ferraresi, No. 31. This, also, is a 
somewhat doubtful case, but, on the whole, with Fin- 
ney, I would admit it, though it is rejected by 
Monod and Vanverts. 

6. The cases of Hill and Murphy, Nos. 40 and 
41, on the basis of a personal communication from 
Dr. Murphy. 

Let us now, turning to the table, see what the 
results have been, and what conclusions, both as to 
the methods and time of operation, will show us as 
to its advisability. 

First, the time of operation should be wisely chosen. 
The best time is not during the immediate primary 
shock which lasts during the first few hours. Hap- 
pily, in fact, it is very rarely the case, .that opera- 
tion can be done within several hours after perfora 
tion, since, the case being under the care of a 
physician, it requires time to obtain a consultation 
with the surgeon, and, when the diagnosis has been 
reached, still further time must elapse before suit- 
able preparations for operation can be made. The 
table on page 227 shows that the second twelve hours 
15 



226 SURGERY OF TYPHOID FEVER. 

after perforation, all things considered, has been 
the most favorable up to this time. Abbe well 
says that it is essential that " the surgeon should 
never be so hasty in getting at his work that 
he enters upon it handicapped by poor assistants, 
poor light, poor arrangements for irrigation and 
sponging, or inadequate plans for restoration from 
shock." The earliest moment at which the operation 
can be done after the immediate shock of the perfor- 
ation, provided, of course, there has been any, as is 
sometimes not the case, the better it will be for the 
patient. Every hour then counts, since the infection 
of the peritoneum becomes more diffuse and more 
intense. 

On the other hand, no prudent surgeon would 
decide to operate in a case in which all the con- 
ditions, both general and local, forbade the hope 
of a recovery. The only contraindication recog- 
nized by Van Hook J is that the patient is moribund, 
but I can well imagine that, as in perforation from 
other cause, the general state of the patient, the 
pulse, the temperature, and the degree of collapse 
and of exhaustion will all count as essential factors 
in formulating a conclusion. Naturally, the cases 
operated on after relapse or toward the end of the 
acute febrile attack will result better than those in 
which the perforation occurring earlier requires the 
patient not only to recover from the operation, but 
to have strength enough to carry him through the 
fever which has not as yet subsided. Yet Finney 
has called attention to the remarkable vitality ex- 
hibited by some of the cases that recover, and states 

1 Med. News, Nov. 21, 1891, 591. 



INTESTINAL PERFORATION. 227 

of three cases "who subsequent to the operation 
suffered two relapses, one, of great severity, had 
suppurating otitis media, left-sided pleurisy, had 
right-sided femoral phlebitis, severe neuritis of both 
legs, and the painful toes so common after the cold 
bath treatment," and yet recovered. 

An analysis of the cases in which the interval be- 
tween the onset of the symptoms and the time of 
operation is stated shows us the great danger of 
delay. This is stated in 60 cases as follows : 

Cases. Recovered. 

Within twelve hours, 15 4 

Twelve to twenty-four hours, ... 20 6 

Twenty-four to forty-eight hours, .13 1 

Two to three days, 6 2 

Three to four days, 4 o 

Five days, 1 o 

Thirty-eight days, 1 o 

60 13 

In the cases operated on within twelve hours, the 
percentage of recoveries was 26.7 per cent. ; between 
twelve and twenty- four hours, 30 per cent. After 
twenty-four hours the mortality was total, except one 
after twenty-six hours (No. 64) and the tw r o that re- 
covered between two and three days (Nos. 25 and 
28). The last two cases we must consider as excep- 
tional and not impairing the rule that if the opera- 
tion is not done within about twenty four hours after 
the perforation there is practically no hope of a re- 
covery. 

TecJinic of the Operatio?i. — The incision may be 
either median or lateral. If the case, by percussion, 
is fairly well proved to be an encysted localized peri- 



228 SURGERY OF TYPHOID FEVER. 

tonitis, I would very decidedly prefer the lateral in- 
cision, just as in an appendicitis with a similar condi- 
tion the lateral incision is preferable. If, however, 
the case is one of general peritonitis, which in typhoid 
perforation is far more frequent than the localized 
form, the incision would best be made in the middle 
line, since it offers far better opportunities for cleans- 
ing the peritoneum, and gives us ready access to the 
ileum, which is the usual seat of the perforation. It 
should be a free incision, long enough for the neces- 
sary manipulations. 

Our first object is to find the perforation. As 
already shown (p. 214), this is usually in the ileum ; 
but if not there, then the cecum, the appendix, and 
the sigmoid flexure of the colon should be examined. 
In the jejunum perforation is very rare, and in the 
duodenum it may be said almost never to take place. 
Sometimes the search will be facilitated by cleans- 
ing the abdomen of the quantities of fecal matter 
and foul pus which coat the intestines ; sometimes 
the perforation may be readily discovered without 
this. If flushing is done it would be best by the 
sterile salt solution, though Abbe used with ad- 
vantage a very weak bichlorid solution, 1 : 20,000. 
As soon as a perforation is discovered, it should be 
sutured. Sometimes the edges have been pared, but 
I see no reason for this, as for effective closure we 
must depend upon the peritoneal adhesions. To 
trim the edges is both a waste of time and tissue. 
But in case two perforations are contiguous, it may 
well be that excision would best prepare the bowel 
for suture. All of the thinned intestinal wall sur- 
rounding the perforation (see page 216 and Plates 



INTESTINAL PERFORATION. 22<j 

IV and V) should be turned in, if this will not pro- 
duce too much stenosis of the bowel. 

In five of the cases tabulated (Nos. 31, 40, 70, 72, 
73), there was such wide destruction of tissue that a 
portion of the bowel was resected. If this condition is 
found, no other course is open to the surgeon except, 
it may be, the establishment of an artificial anus, 
which may be closed later. As a general rule, I rather 
prefer the latter course ; but it is an encouragement 
to us to find that the first two of the cases of resec- 
tion recovered. An artificial anus in the ileum I 
have found in cases other than typhoid to be objec- 
tionable, since the intestinal juices are very irritating 
to the skin. 

A continuous suture is decidedly not the best. 
The tissues of the bowel are very frail and may 
readily tear out, and, if the suture be continuous and 
it tears out at one point, it weakens the whole line 
of suture. Independent mattress sutures, as ad- 
vised by Halsted, are the best, not only because, 
as Abbe found, they do not so readily tear the 
friable tissue, but also because they shorten the 
operation, since there is but one knot to be tied for 
every two sutures. Whether one, two, or three 
rows of sutures shall be applied depends on the 
case, but we must remember that every additional 
row narrow's the lumen of the bowel. As soon as 
one opening has been closed, a search should be 
made in the regions above indicated for either a 
second perforation, or possibly even more than tw r o, 
and also for any suspicious weakened spots which 
show that other perforations are imminent. In cases 
5 1 and 60 subsequent perforations destroyed life in 



230 SURGERY OF TYPHOID FEVER. 

cases which were apparently recovering, and in case 
62 had life been prolonged a little while a new per- 
foration would have occurred and ultimately killed 
the patient. In two other cases (40 and 48) such 
suturing at points of impending perforation probably 
saved both lives. 

How far the search for multiple or impending 
perforations shall go must be decided by the opera- 
tor in each case. Very prolonged search over a large 
portion of the intestine involves both time and added 
shock. Most of the perforations occur within six feet, 
and especially within the first two or three feet of the 
ileo-cecal valve. If none are found within this dis- 
tance nor in the other regions of probable perforation 
(vide supra), I think, as a rule, it would be safer not 
to prolong the search further. Fewer lives would be 
lost by such abbreviation of the operation, and by 
avoiding the necessary mechanical injury and cooling 
of the intestine, than by missing a very exceptional 
second ulcer at another point. Whether we shall 
only flush the abdomen, or whether we shall clean it 
by wiping, is, I think, to be decided very much by 
later experience. Finney 1 has made a strong plea 
for systematic wiping of the bowel with pledgets of 
gauze wrung out of a hot salt solution in suppura- 
tive peritonitis from whatever cause. 

In no case, it seems to me, should the abdo- 
men be entirely closed. Drainage should be the 
rule. If peritonitis arise from other cause than 
typhoid perforation, scarcely any surgeon would 
think of closing the abdomen ; and the same rule 
should, hold good here. Moreover, I think well of 

1 Johns Hopkins Hosp. Bull., July, 1897. 



INTESTIN. I L PERFOR. I II ON. 23 I 

packing the wound with iodoform gauze, and I would 

prefer that the point or points of suture in the bowel 
should he placed, if possible, immediately below the 
gauze packing, so that if a fecal fistula formed, as 
occurred in Abbe's case (No. 25), there should be a 
ready and unobstructed egress for the intestinal con- 
tents. In spite of the bad condition of the patients, a 
number of post-mortems have shown that the wounds 
become agglutinated and heal as well as other simi- 
lar wounds in the intestine. In case after case of 
those that died the post-mortem showed that the 
stitches had held perfectly, and that no later extra- 
vasation had occurred, though this took place in 
Lucke's and Kimura's cases (Nos. 2 and 14). The 
very fact that such wounds of the intestine heal 
readily is a great encouragement. 

The cause of death is commonly the septic 
condition or the profound exhaustion which has 
been produced by the fever ; to which the opera- 
tion, unfortunately, as a rule, can but add some- 
thing. 

In every case, before the abdomen is closed the 
appendix should be sought and examined. Typhoid 
ulcers are sometimes found in the appendix. This 
part of the intestinal tract, therefore, should never 
be overlooked. If true appendicitis is present, as 
may occasionally happen, or if a typhoid perforation 
exist there, the appendix should, of course, be re- 
moved. This was done in several of the cases in 
the table. If, however, the appendix be not diseased, 
it should not be removed, as it adds to the length of 
an operation in which every minute counts. 

I have recently operated upon two cases of ap- 



232 SURGERY OF TYPHOID FEVER. 

pendicitis in which the first attacks followed shortly 
after typhoid. As in neither case were the typhoid 
bacilli found in cultures from the contents of the 
appendix, the connection between the two diseases 
seems to be accidental and not causal. In the last 
case, over three years after the typhoid attack, the 
blood reacted to the Widal serum-test; the ileum 
showed several oval white patches, corresponding to 
Peyer's patches, and the mesenteric glands were 
greatly enlarged. The bacteriological examination 
showed the colon bacillus and the micrococcus 
pyogenes albus in a tube inoculated from the peri- 
toneum, the colon bacillus and micrococcus fcetidus 
in the tube inoculated from the interior of the appen- 
dix, and the micrococcus pyogenes albus in pure 
culture in the tube inoculated from a mesenteric 
gland which I excised. The gland itself, Prof. Cop- 
lin reports, showed areas of coagulation necrosis 
with softening. In spite of the infection of the peri- 
toneum, the patient made a perfectly smooth recovery 
from the operation, but still has a hectic temperature 
— suggestive of tuberculosis, though there are no 
tubercle bacilli in the sputum. 

Unfortunately, in Case 44 intestinal obstruction 
followed the operation and was the cause of death. 
I can scarcely think that we would ever be justified 
in re-opening the abdomen in such a case. Possibly, 
a very exceptional case might justify such a proced- 
ure, but a typhoid patient rarely escapes with his 
life, even after one operation, and could not be ex- 
pected to survive a second. The same remark 
would apply to any new perforation which might 
occur. Such cases must, unfortunately, be left to 



INTESTINAL PERFORATA 233 

their fate, but if the surgeon has been careful to 
search for and suture any impending perforation, he 
has clone much to prevent such a disaster. In Cases 
40 and 48 the suturing- of such an impending perfor- 
ation undoubtedly saved both lives. 

If there be such distention of the intestines that it 
is difficult, if not impossible, to replace them, they 
should be incised, and, after the gas has escaped, 
sutured. This was done in several cases. 

Mr. Gairdner, Assistant Physician of the Belvidere 
Fever Hospital, in analyzing 47 cases of peritonitis 
in typhoid fever with reference to surgical interfer- 
ence, in a very careful and judicious paper in the 
Glasgow Medical Journal, February, 1897, page 67, 
reaches the following conclusions, which well express 
my own feelings, and it is all the more worthy of con- 
sideration as the opinion of a thoughtful physician 
rather than that of an over-sanguine surgeon : " The 
treatment of peritonitis in the course of enteric fever 
by laparotomy has hitherto had a moderate success. 
There is every reason to believe that greater success 
is possible, and in any case the results are better 
than those of any other treatment. Laparotomy 
offers a fair chance to about 49 per cent, of cases, while 
19 per cent, of the whole would certainly have a 
good chance. Nothing but experience can determine 
what the results will be — better or worse than might 
be expected prima facie. If there is a good cause at 
least for attempting surgical interference, it becomes 
incumbent on the profession to afford every facility 
for making the attempt. This, of course, applies 
particularly to authorities responsible for hospitals in 
which enteric fever is treated." 



— TV.VH3.LXI 



» y ft C — cs 



- > y< 



■a w •- o • 



cj a 

-%*•% « £ 5 g.S 



^~,_ ??O.b0, 



5 c « 






y cS 



•- >, <U y en 

Sua 5S &• 



3 y ^>>5 





•- 

y 
< 


p 


if 




u 









V. 


a 




y 

CO 


3 


u 


en 
cu 

— 

cd 





u 


■£ 


o 




"3 

CU 


"3 . 




E 


E. 


5 


< 


CO 


z 


~ 




btfi 


u 
y 
en 


S. 5 


VO 


P 


— 


o 


p 


A 


P^ 

C3 


•n.isHH 


^ 














P 




P 












P 


P 




o 


R 


P 


■xoix 
















en 




■Ji 














m 




en 




W 


-VHHdO 
















5 




4 














3 




O 




O 



gSSg 



JlfJ 



£ 


3 3 




3 a 






.2 « 


rt . 

- '5 v 


|«2 


— y 


— = * 


£s 


gyjg 


Ed 






O 3 


X — — 


|8 

y O 


(USD 

— -, o 


'O-i 







,a •_ 



.3 = cj y 






= >, _- 
.2-^3 






be -■ CO 



2 2- y 

— _; ■„ J^j ™ — „ 

— y.h nixl* £ 



3 z 



< K 

y < 



2S = 

— > en — ^ 











y c o 




cd 


o 


rt 




- 


> A 


X3S 

30V 


* 




di 

cc 


cc 














oc 


W 
U 

z 


= > °c 


X 

e 


N-3 

"y i_* 

we 


~ 3 

>y e^ 

►r o •' 
x = , ^ 

'- ~ x 
tc - 


=" > 

o o 

si 

•- — 


"d = 

y rt 
§^ 

. cc 

A* 

CN < 


1 


oc 

CO 

en" 

y 

y 

s 


J 

y 


<U y — 
"5 in S 


c « b a 

uOZ o 

cn — ~ — es 

21 l^g 2 

en 7, "C ~ U en 
y > r. = h« « 

i. U y U U 

iJC "C en = M 



~, 5 



2 J DC 

« w r^ 



a a 



V s o'o tl . 
g.ts a« .a 

c r- 5^-; 

> a j2 *2 

S a \%% 3 a ! 

. ='= E a - 



Q < = .-■-* 
- . «> cS 81 



K «2 c in 



tf] l» 0> .O e 

o 2h 8.0 

.3 





£8|i2g.A 


0*3 


2Q.|g.2"5 


u ~ 
0JT3 


1-9 i^p 


oe 






- u 

3 = 




c/l 



2 - .■ 



- i- © 



B •-P.5.W.2 _• J 

3 Z Z 7-.<.- 



2 Z Z 



3 5*3 
o 2.2 g 

^ 3 «. 5 



-a 


g J 


y 


if 




'^ « 




— 3 


X! 


5 "3 



M & o 2 

a: bO -3 3 
> cd _x rt 






3 «J 3 
c/3 rs lT> 



C/) — 1 -1 ' 

W 2 B-Sj3 


— ?' 




.Q 


• — "3C l1 


C/3 


TJ UoW 


11 


U'O'n'S 5 


— ■„ 


J = u bC = 




w 2 h'C 8 












M c~U 


ti 








c/1.3 


~oo^ 






5 d S 2 


z ~ 


a £ >, s s 




a,ox>2 5 


- V ' 




£ u - 






"iV. 3 K U 


y v rt b5 


ja o.oja - 


.= bccd 



O V 

S52 



- u 

3 CI 
CT..-3 



►,•0 • 



IMS 

3 M >, w 

U <rt 3 



S.2> 



E.2 



> U 3 ' 

c- . 



.- 3 bCx(Nj> 

•- > bC U y: 

^ - . . tJ . « 



"S 5-" 

='< 5 



y v - 
y >■- 

— — y 

- > > 



4*1 3 O ,M 3 O -0*g <> 

«U rtCJ^ 1 § cd - 

El e ^ Hh. e u J «* <" 



"3 y "" oc 

y w_- co d bc_- x - o 



^2 2 3^1 £^* 









if ^ "7 oo 3 " 
M rt O (fl g .2 









s s 



& 



tn 


~ 


- 




e 


'- 


- 


~ u 




? 




% 


irt 


= 


- 


= 


jO 




^ 

2 


a 


y. 


- 


o 


z 


= 


— — 


-. 


— 


pj 


— 


N 


r. 




u 


^. . 




> 

- 


y 


> z 


a 


— 


a g 

- M 






y- 




y 






- 


— 



z 



M . M • CI 



^•■§2 



< X fc 



Cti '.3 S- 4> 3 <« 

* § 1 <n 60 I 

o v" 

s a 



c"2 



S x o."5i w 




c 












"S"!* 




x 














u W -* ~ - 






U 3 « c O 




in 








s ^^ - s 




■«J 


ir.~ u 0*3 




_ . 


^ = 1> ~ -; 






5 M --e«s 

- - « - 




— cd 






Death 
ought 

Mild b 

d lea 


£ 




5 Jfv=5 


£ 


s< 



= o 

o c 

. K 
3 — 

.2- 
"5 - 

j= a 

'-> & 

z C 

& c .2 

jfl o - 

— '.- i 
-5 E 



•-unsay p 



•xoix 

HaoHHa 



X 3 — ' 




ii— 5 


I« 




*! > 




rt o 


*jS S 


on 


x 3 - 
3«2 <0 


3 '- 


a j-C 


a y 



Z 5-c- 



^ 5 »>Xi 




•-«- 


~ rtjg be 




2 5 2 






" ° x 




£,E* 


OM§X 




fcm? 


d.5 2 w 

"~ ' <u E u 






X _, - _, 




2 - u 


"2 X ° = 


j.j 


■S«-p 


X O ° w 






U CJ >._, 


o 




Ilcer 

! 11)11 
her I 
mber 


75 


.2 5 J 



c-3 > c- 5 E 
o-r„c -— - a r 



z U 

S a, 

•E o x 

■Ids 






U^ U r^ in 
S. <0 « >> 



* & • 3 -S 



a^.2-| 2 -C.g^ 
F"5^: * Q/-3 £'> 



z 

< s 






<~ 






Q fc 
Z ° 
< ~ • 



3* Sx 



> ^ 



H*3 



^< | Id • 

• _• 3 C C — = 

^ ■ O^ J - - - — 

BgSdJ 5 -8? 

■ -x - ^,S a E 



— • a 
v kg. 
b>= = x 



3 "^1> 



- a 
> o 



•XHS 


S s 




§ 


s 




s 


s 


•30V 


ET ft 




r<3 


m 




?i 


u-. 




„• •« 


" - — l/. 
J — K ON 


3 


J 


J 


r 


•-. 3""^ >" 



3: o - 

=2 - O 1> ON 






?i S - 53 






u O 

£3 



_■■■= 
_ c 
— u 



3.9 *■ 3 a 



liS 5 




3 S _■ = 

3 o C 

v c 2 a 

51 l-s 



J- . f — 
ed v w «j 



Q Q 2 



3* 



0.0 



3 W 5 « 






1 " 3 U 






'Em 



2 P. 



,£ O 3 o i- 0.-S . o 



>^ j-,S-c~£ 



, 01 O D 

=5 H8 S- a." 



-- ._ .. .. 

E ? 0) U£ 



>• t/l 5j — ~ — . 






c o'S 



3 C.S > 



I. b£ Co 

££ -* 

u . = " - "-'- 

' 5 a! 5 £ ? 3 
■ Sb'Sb | 

075 x r.— 



u a & 

of «5 



If eg* 



o 

a 


V 




- 






o 




























o 


- 


« 


sc 







i 










J. 


<J 



5 c5 



v - 

— - 

,0 



E 






= : ^ 

oo 



ft B ed 



y b-i 



° C rt 

rt E 
O 



-r. — — ~s •* 



y r> »j U . 



— = c . • - 

% « « -° 3 

7 ?= = 



cj ft 












"i2cB 



e £^ 



<U O u 
zi — • _- to x 



— 






ir. O 

— U 

-r 

r!J3. 



3 — T3 csQ 
T3 CCTJ 



o- 



■xinss-a 



•noii 

-VHHdO 

aaoH3a 



Q Q 



g ! 

w 



b u 

o z 



< o 
O 



g 3 

c 






•XHS 

•aoy 



_' S- 11 

2.2 •§ 



'bfl*W 



« . w £ • 



4>T3 
O 2 



- 1 ~ P'V 



E - - 



o o 

Jill 

ft — >^3 

CCX3 Ctf 



3u 
— c 



~ <u c u 



It 



o c - 



& 5 

ft c 



u 


SS o\C w 




.a t^o o 


C 


o -; 


T3 On 


S r u * 


1; ■"" 


o > ~ 


£ft 


3 "".*- IT 

^ C^«£ ON 



£ 



= "3 1 . ° 

32^(0 
O — 3 f 

o c 



5 3<3 <" o O <u 
3 O n>7 w <« 



C 4) 4) - 

3 ax5 F' 
.2 «So' 

5 3 «C 
4) CS ^ — 

JH S w w - 
i2gS|ft". 

£ S* O 3 



r. 2 m 

! II. 

5 "oS ; 



3.3 * > 

£s 2 



en +^ 

c 

S <u 

x_o 
£ "3 
"e <u 

4J-5 > 



CQ 

-a 



DX 3 CO 



3 ~ X _ 



^^5ft 

fe m o c 



s* 


°^ 




V 


> H 


-i 






^ = 


< On 
OS 


>— 1 


'- 


£ 


W 




u 


[fl 








UO-^ 










^ 












«I 


rort 



< ~ ° 

.■!■? ^ i 

2 a § ■ ■ x ^ ■" " '- : 

rth'o ~ • - 

a Ku r.c =- 5 

„ x> <_ . . . re - re - ■_ 

&oo . &£ 

-i^ • • • 3 2 8 1 

oSJo 



"o 8.8 

-= </> (J > 



a c © -a 






_ ~~ — v 

- 1**1. 

sj- 5 * = ' /; .§ 

■- «> > S 5 

/ - / o ■ — - 



Mi ,, 
c 9 _ 



— ■ re • — "C-X2 sz S '" — rr^sbn, rt"~; Si St 5 St <■ . — Si — ~ ^ — ~ ^ £ 

*|SJ.a *■§&. "E^-r^ C E •«« u-S&g SE «£"»* = 

^ = recJi==rere^^Eo w acjs5*«Oo sSoBoSfl^wHca*: 

||xi!II1 I "TV - I 

£( %°s * I = 






E . o. 

k*S>i« so^- 



g,cM« N =: .rre^re-reu « « <w 

■2 C S>«'§ § s rt ^iS.S.a r -^ :_-E. 

^ & > « ««.o ■= ? ^ = = =-"> 3s 

V- J— .- .-> M.S- >- ^ 5— <u.O C >>13 J e u fi 

S a; o v o c-- - j£ S o * rt r, = r- 9 re X -a " 



o— • 



-Xit^ 1 w-n, 



^-OO ^ Ss- J}, 



M 


M tA 

3 > 

Cfl o 

re <^ 

00 




E > 
UJ o 






°4 

bft- ^ 

re_: c^ 


o - 

li 

5 
u 


li 


-a H 
<l> r 




— 
5 - 


i - 




5:^ 




a 


a 




=- 


m« 


--- 






3 *b 



= ~ « s 5 >,<£ 
q 2J <8 « ■£ - 5 _; 

^e ° = o 5 "<° 3 

g >,— o v o 55 ~ o 



•xi.iSHy 



o=<^ 



x — = ~ - 
:boo« 
5 >~z_o o- 






"•o ^ JJ ^ o b 
".3 -£2 "9 « S O 

S i. " U T) H N 



,1CX ^ 3 •- U 

g'g-Ss^gS 



> 5 tr. 


3 W O 


— CfO 


5 a° 


*$Fg 


3 O m 


O (LI x? 


l *" 1 O id 


§ V o 


rtB N 


iuog 


"^ £ J 


ill 


^^ 5 




°-- c 


(J 1 - ST 

.2 >.g-g 






* t-i ii "d Sc 


S'u_i rt k « 

.3 S cS U 



"NOIX 

-vaaao 

3HOJH9 
1VAH3JLN] 









5 5,2 



=- gj ■ u 



SS' 



-§ = § 










z - 5 










3 


cs 






- - z 

- u 7 


= 


= 








C ■- 






u <- 


§§ 


%i 








~ 6 "lev xv 
~H W 15 cn"S 






q s 












-u 


-~ 


'— is 






">13 








> 


> 






> 


> > > 






•xas 


S 


s 






2 


s s s 






■30V 


<*3 








X 


t^ cc oc 








- 


^. « 


- 


- 


,2co 


r-T3 r— r-c 




r-s 






.a -a 


























5 « . 


u 


ON 

oa 


^"3 


§ 


X 


«=5 H 


O .u'O - u o - 




*tffc 


7- 


«M 


V 


-^ 


« -if 53 ~ « 5 " 


J 


13^5 


- 


■£ 


c^o 




J. 


Si 


^•3^§a 


* 


^.5« 




3 


u "5 

5 


o 

< 




io 5 " |_| 


.ti •*" o ■— '"" o •— "" 




•- •- 5 


X 


>J CO 


ON 

X 


^•5 3 ^3 


00 ou oc JJ 00 


J/3 

5 


*H 




,. 


t 














.; 


= 


3 






- 


w a a 




w 


I 


X 


P5 






O be 


6 fci 6 w O bio 




d bi 





















B. 

_ 










. 


. o . o . o 




. o 




ON 






cc V. 


o?2 a?2 i?1 






a: 




















*©" 


— 






n< 


«5< ^< lo< 




nO"'< 




i/i 


1*5 






*r> 


V) IO JC 




JW 



•CO J) 

Xi r; 3 

■3*2 



<=: §• ~ « 

en'*" o 



-~ ~ ~ 






2 - 



Q 



• r . cd ~~ 
0.52 

J- « 3 
~ 3.0 
« ~ 

w .3 - 

.- (A) 



— « , 

-' - ~ ' 

r: r. ~ Zi ■ 

V V 3 n 10 

x> « 



>«.2o, g . 

\Z .3 — £ «> 
gd * «D 
'- w t M C 

a o£-. «-a 



- y~ 

■5«o2 



^ 



x> ic 
o 3 1 — 
u 

5.! 



- g 



t> « s 

4>S_ 3 



<x> 
b£ . 

> be 
ed cd 



Bis a 


3 rt 




U) > 


. 




- w 


^"C 


- EJ 








u x> 


. =X) 




3 XI - 


W-=« 


a j. 5 



ii* 2 i 



= •--;" 3 5 — 

xi ii_ r; w, 



1.5 



u s 
1 1 « 

3i . 



i-S'Sl^oSl* 



5 "- H.~ ■-• * 



r" a ='- 3 



E ? 



: 'S S VSe 



- w 



*j ■= - « en «J '5 • 
3.3— u-r; M -p— 

£<_ 5-2 "5 ° "■ 
a K O J J2 Q 



_>>u »***;« M ^_ 



s 3 - y — '-} ~ a 

sSfrSg b .-s 



xi ~-— ^.a 



* S = - 3 3 C 



o 



s S^-^ 3oO 



= -■ 



£w^Ji§S« 

xi — « '3 o 



.5 ? ft 



£^ 1 
5 5 

w5- 



<!««£> 



5 _; _ 




o - u O > u jjjj £ _. o g 

— O S ~ \0 -e '„ -"3 -_ % °^ 
XI ~*Ji XI " Ji Xi^g.^-vo" 3co 






— o 

- ON 






bi r 








< ~ 










— ; m 

v r« 


W Q 


«*a 


6 


«i 3 3. 


^^ 


- <4i 


i^; 


o->^? 


cc 



^•> 



d M-- 3 .;. 
» ^ a. < 3 



O bi 


O bi 


CJ 


=5 


M^ 


. o 


. o 






. ^ 




$ g 


ON 


NO 
ON 


NO O 

ON3Q 

00 "^ 


^< 


00< 


O? 


o" 


i— iC 


IC 


1^ 


ifl 


NO 


NO 



fi-S 



— sd 

nO 



IT. O 



v.z. in 
^£° 

-Xi 3 

S S c 

<L> >- U 

Era 



U 3 



•nnsHH 



•NOIl 

-vaaao 

aaoaaa 

'IVAa3J.NI 



Q u 
M u 

O 



2° 
< 2 



X O x 

't- < X 
< ~ ~ 
u < 

o I 
JU 



.3 



i> re 



S S ^?lr3 



•fi -= <u c u 

^« c g .2-32.2 g-oE-o ■£«■*. 



T3 S.E to O g 

5=^3 S S 

■*"! en * be *3'3 






« '" " aj in u *C 3r; K T"r" .r/ - 

= •- & X! j ° ?v< £~ jz -r - o re 



- y = .<« -rsti 



! CC cfl 
!j3 0) 



bfl 

biS 



OopjiiiSoSi 

cn.5 £ £ 5-J a-./} ^UU^ 



; - cu- 
rt— 



£ <l> v 
— ■c 01 
y re o 



£ «S re 



;°£ 



cu - 



> 4J 2i 
re-C 



re 1 ^ be 
cu -: o 



S re 5-5° 
> <u v 



> 

-a c 

re re 

en 

x j; 

cJ5 o 






•xas 
■aoy 






o t>" 






00 c 



£ d 




^ d 


^ d 










cn _ 




en _ 


en _ 






































t-^ 












dYi 




a^i 


a^ 


o 




c 


o 






















re s- 


re u. 


J2 
U 


1 > 

o 


uS- 


uS- 






i* 


i c 


cy o 




% v 


(L) rc 


iiQ 













o£ 






T) 


-0 






^s 






cn 


w.c 


tf 
















o> > 


a 


o > 




vO 




r>. 


1^ 






1) If! 









•: - - ■>. a - 
y.z s a »; B 

a - - r _ 














-2 .<■£*! 

« 5 m o» o * S 






ti 




i. 






— 






_^ 


o 


z 


£ / rt « c od 

3 "O * ~ ^ 

g > a >> « rt _ • 










X 


f 


SI 


— 
11 

3 


u 

Q 


re 


Died 
cropsy 

tonitis 
Died 
from a 
tinal b 
tococci 
prior h 












Q Q 



5 -£ 

— o 



re = 

n 

. 3 

u >. E 
.5 « — 



ll 



.OS 



o 



•a c 

= < 
O 
; '3 



2.5.2 

■ - S « 

S <U « 



to 



Ifl 


",• i « 


uidoned 

ed wall, 

lumen. 

rainage, 

ial wall, 

around 


> ~ - 
o a g 

U.O 4J 





Om sc 

.Hi 5t 


C 


it ab 
cken 
ing o 
ford 
itesti 
icked 


H.5?$ 


•= - 


a--,'' * 


■-** S| u^ 


M U 


Q *-' 


p.- _• V 


i = ~ x^ = 





C <U W </! r ." 

c= o 



l a x « <" £ a >- 
i« a o id « U. 



: 2 I 



• = - E etf £ „ 



• - M . _ 

i X C M '- u 



o WO 

> o 

O <£— 

Si 5 « 8 
■5 3 * * 



3 S I s3 






ai x 

~-z 



< = 
< 



CD 

3 a 



3 Xi 



a j * 

JfiU 



in-: 



-^ c >. 


g cr 


Eigl 

valve. 
pencil 
thicke 
near 1 


»58 


> bd 



s ?. 



^ X X X II 



- X 




a^ 


a^ 




^ 


^d 


5 


- 


- 




2 






c 





-c^n 


o 














5 u 


1-^ 
o 


'« -* 






in 




U 

a 


U 


(A 

if 




n 


U 


U 


^ U^ 


■x. 


O 


a Z 












j>J3 




i • 


JL 








• . 


. ■ 






, . 


1 i 




u > 


'p' 


"v 
Si 




ID 

.2. 


U c 

DC 

< c 


u o 


< 

a" 




i2s 
u o 


ON X 




On " 


On 


3n 




On 




. - 


..• 


b£ 


-- 


















































i — i.ti 






i ,:^ 








X. 


J] 7i 


u 


c 


- iu 


N > 




"5 > 


-to 


IC 




o 




;x.- 


- o 




o a^ 






t^ 


t^ 


r^ 




r* 


t>. 


r^ 


r^ 




X 



" " o - ? = ^ 



CHAPTER XVI. 

TYPHOID AFFECTIONS OF THE LIVER AND THE 
GALL-BLADDER. 

I. Typhoid Affections of the Liver. — The 

intimate anatomical and pathological connection 
between the intestines, the liver, and the gall- 
bladder, especially through the portal circulation and 
the biliary ducts, is self-evident. The commonest 
cause of abscess of the liver is through an infection 
following dysentery and similar intestinal diseases. 
It is not surprising, therefore, that a disorder like 
typhoid fever, of which the essential lesion is inflam- 
mation and ulceration of numerous areas of the 
intestinal mucous membrane, should occasionally be 
followed by abscess of the liver. Holscher 1 found 
parenchymatous degeneration of the liver in 203 
out of 2000 fatal cases — over ten per cent. In view 
of this fact, and of the thrombosis of the vessels of 
the liver by the typhoid bacilli actually observed 
by Fraenkel and Simmonds (Plate I, p. 62), it is 
rather surprising that so few cases of abscess should 
be reported, seeing the inevitable exposure of every 
such patient to the possibility of infection by the 
typhoid bacillus, the colon bacillus, and the ordinary 
pyogenic bacteria. Yet in my first series of cases, 
not one case of hepatic abscess was tabulated. 
In the second series only 21 cases in all could be 

1 Munch, med. Wochen., 1891, Nos. 4 and 5. 
244 



THE LIVER AND THE GALL-BLAD&ER. 245 

found by Dr. Westcott, the first case being that of 

Louis, in 1841. A number of cases alluded to by 
various authors, but not in such detail as to allow of 
tabulation, are necessarily excluded. Even of the 
cases tabulated, in one 1 the diagnosis of typhoid is 
doubtful. 

Typhoidal hepatic abscess is in most cases primary. 
Whether it is the direct result of infection by the 
typhoid bacillus or not we have too few bacteriologi- 
cal examinations to decide. Dupre 2 obtained a pure 
culture of the typhoid bacillus from a case of angio- 
cholitis six months after the fever. In another, 
Rosenberg 3 found the staphylococcus. Most prob- 
ably, in the majority of cases the pyogenic bacteria 
and the colon bacillus are the immediate cause, while 
in a few the typhoid bacillus alone may produce the 
abscess. 

Instead of being a primary infection of the liver, 
the abscess may sometimes be secondary to typhoid 
lesions elsewhere, especially if these become infected 
by pyogenic bacteria. This is really a form of 
pyemia. Thus, Louis 4 reports the first recorded case, 
I believe, of hepatic abscess from typhoid, in which it 
arose after an abscess of the parotid. Romberg 5 
refers to two others arising, one from an abscess 
of the fourth finger, and the second from a thenar 
abscess. Another case is reported by Chvostek, 6 in 
which it was secondary to a laryngeal perichondritis. 

1 Daly, Medical and Surgical Reporter, 1882,346. 

2 Les infec. biliaires, 'these de Paris, 1S91. 

3 Berlin, klin. Wochen., 1890. 192.. 

4 Recherches Anat. Path, et Therap. sur. la Fievre Typhoide, 1841. 12th 
ed.,p. 118. 5 Berlin, klin. Wochen., 1890, 192. 

6 Allgem. Wien. nied. Zeit , 1866, No 37. 



246 SURGERY OF TYPHOID FEVER. 

BurJer l has reported a similar case. In these cases 
the abscesses are multiple. 

Solitary abscesses are more common, but even 
these are very rare. Langenbuch 2 refers to several 
cases to which I have not had access, and states that 
there are on record about 20 cases of typhoidal 
abscess of the liver. Besides the five cases of mul- 
tiple abscesses, Dr. Westcott has only found 16 
others. To these should be added 1 2 cases found 
in the Munich post-mortems by Holscher, 3 but which 
are only tabulated so briefly that they can not be used 
in my statistics. 

Of these 2 1 cases, all died but two. Not a few were 
only found at the post-mortem, since in the dulled 
condition of the patient no complaint was made of 
any hepatic symptoms. 

The two cases of recovery are as follows : 

Case XXXV/ff (DelaAre 4 ). — A woman of thirty- 
four, when convalescent from typhoid fever, was sud- 
denly seized with pain in the hepatic region, followed 
bv enlargement of the liver below the level of the 
umbilicus by the twentieth day. Two days later she 
was seized with sudden thoracic pain, and was nearly 
strangled by an immense quantity of pus which she 
expectorated, an abscess of the liver having evidently 
ruptured through the diaphragm and discharged 
through the lung. She recovered her health en- 
tirely, when a year later a renewed attack of the 
hepatic abscess occurred, and ruptured at a spot near 
the right iliac spine after the use of Vienna paste. 
Finally, however, the abscess had to be opened, and 
she recovered. 

1 Lancet, 1874, ii, 552. - Deutsch. Chir. Lief, 45 c. Erste Halfte, 238. 
3 Loc. cit. 4 Gaz. des Hop., 1869, No. ill, 437. 



THE LIVER AND THE CALL-BLADDER. 247 

Case XXXIX. — Sidlo ' reports the following 
case: A girl ten years old became ill with typhoid 
fever at the end of February, 1873. By the fifteenth 
day defervescence had occurred. On the seven- 
teenth day, however, she complained again of head- 
ache, and had marked chills, followed by delirium, 
enlargement of the spleen, and meteorism. On the 
thirty-second day she first noticed pain in the hepatic 
region. Three days later there was marked swell- 
ing, with jaundice. On the forty-fourth day there 
developed also fluctuation, first over the left and 
then over the right mastoid, and in the right temple. 
After these abscesses had run their course, she com- 
plained of pain in the region of the fifth and sixth 
ribs, followed by swelling. The whole axilla in a 
short time became a monstrous abscess, and she lost 
flesh to such a degree that she was little more than 
a skeleton. On the eightieth day the tumor in the 
axilla began to shrink, and on the eighty-fourth, 
after severe pain in the abdomen, she began to pass 
blood and pus by the bowel. In the afternoon of 
that day she had 25, and in the. night 10 additional, 
movements. On the next day there were 20 other 
movements, during which scybalous masses and pus 
were passed. With this her liver dulness and the 
jaundice diminished, and on the one hundred and 
twentieth day she was entirely well. 

Surgery can do but little actively in these cases. 
The treatment must be entirely symptomatic. The 
few that recover will be most fortunate, and owe 
quite as much to nature as to the surgeon. 

Suppurative pylephlebitis occasionally, but 
very rarely, follows typhoid, and is sometimes the 
cause of abscesses. It is probably a result of throm- 
bosis of the vena portae. Buckling 2 found throm- 

1 Der Militar Arzt, Wien, 1875, No. 23, p. 20. 

2 Falle v. Leber Al^cesse, Berlin, 1868. 



248 SURGERY OF TYPHOID FEVER. 

bosis of the vena portae in two cases. Such thrombi 
would readily become infected by any of the bac- 
teria above mentioned. 

The pylephlebitis may result in abscesses proper 
in the liver, as in Romberg's case, 1 in which the 
thrombosis extended from the ileo-colic veins to the 
portal vein and its branches in the liver. He refers 
to four other cases. Staphylococci were found both 
in the thrombi and in the abscesses. 

Osier, in his extensive pathological experience, 
has seen but a single case. 2 In this case multiple 
abscesses occurred in the mesentery, which " fluctu- 
ated like a sac of pus." " Outside the liver the por- 
tal vein was represented by an elongated abscess 
with thick, irregular walls." The splenic vein also 
was closed by a thrombus. 

In Lannois' case, 3 a man of thirty-eight died three 
days after admission with typhoid pleurisy and sup- 
posed tubercular peritonitis. The necropsy showed 
adherent ante-mortem clots in the portal, splenic, and 
inferior mesenteric veins, with numerous abscesses 
in the liver, in which was found the typhoid bacillus 
associated with other organisms. 

In these cases, also, surgery can offer no help. 
They are necessarily fatal. 

II. Typhoid Affections of the Gall-bladder. 
— In striking contrast to the rarity of surgical com- 
plications and sequels of typhoid in the liver is their 
relative frequency in the gall-bladder. As this sub- 
ject is of great importance, and is comparatively new, 
I shall consider it somewhat fully. Dr. Westcott 

1 Loc. cit. 2 Trans. Assoc. Amer. Phys., 1897, xii, 382. 

3 Rev. de Med., 1895, 909. 



77/ E LIVER AND THE GALL-BLADDER. 249 

has tabulated 74 cases of typhoid infection of the 
gall-bladder accompanying or following typhoid 
fever. Of these, 30 resulted in perforation. 

Five important papers have been published 
lately in connection with this complication. Curi- 
ously enough, two of them were presented at the 
same meeting of the Association of American Phy- 
sicians, in May, 1897, and are to be found in Volume 
XII of their transactions. One is by A. Lawrence 
Mason, on "Gall-bladder Infections in Typhoid 
Fever" (p. 23), the other on "Hepatic Complica- 
tions of Typhoid Fever," by Prof. Osier (p. 3J&), 
in which he includes affections of the crall-bladder. 

o 

The most important papers preceding these two 
are one by Chiari, 1 and another presented by him to 
the International Medical Congress in Rome, in 1894. 
Another important publication is that of Dupre. 2 
Murchison and a number of other writers referred 
to suppurative or catarrhal inflammation of the gall- 
bladder in the same year in which my Toner Lecture 
was published (1876). Hagenmiiller 3 collected 18 
cases. 

As in so many other surgical relations of typhoid 
fever, the discovery of the bacillus of typhoid has 
thrown an entirely new light on both the etiology and 
pathology of the disease. Gilbert and Girode 4 first 
demonstrated the presence of the typhoid bacillus 
in a suppurative cholecystitis in 1890, and followed 

1 Ueber Cholecystitis Typhosa, Prager med. Wochen., 1893, No. 22. 

2 Les Infections Biliaires, These de Paris, 1891. 

3 Cholecystitis Typhosa, These de Paris, 1876. 

4 Contribution a 1 Etude Bacteriologique des Voies Biliaires. Mem. de la 
Societe de Biologie, 1890, La Semaine Med., 1890, Xo. 58. 



250 SURGERY OF TYPHOID FEVER. 

up the subject in a second paper in the same jour- 
nal l in 1893. The bacillus of typhoid has been 
found not only during or immediately after the fever, 
but also at periods long after the fever. Thus, 
Dupre 2 relates the case of a woman of forty-five, 
who died after the operation of cholecystotomy. The 
typhoid bacilli were found in her gall-bladder six 
months after the fever, and Chantemesse, 3 in a simi- 
lar case, found them eight months after the fever. 
Von Dungern 4 reports the following very remark- 
able case, in which, after several recurring attacks of 
different disorders, presumably nearly all due to the 
typhoid bacillus, an abscess finally formed around 
the gall-bladder, possibly due to perforation. In 
the pus a pure culture of the typhoid bacillus was 
found fourteen and a half years after the fever, and 
the blood of the patient reacted promptly to the 
Widal serum-test. 

Case XL. — A woman, age forty-six, was ill of 
typhoid fever in November, 1882, for four weeks. 
There were no symptoms in the region of the gall- 
bladder. In August, 1887, she suffered from a mis- 
carriage, at the end of which she suffered from pains 
in the region of the heart, with severe vomiting, but 
without jaundice. In May, 1888, and in February, 
1889, similar attacks came on, in the last of which 
she had some jaundice. A similar attack again 
occurred in June. She was then well until July, 
1895, when she fell ill with gastralgia. In Septem- 
ber, 1895, sne h ac ^ an attack of periostitis of the 
lower jaw, which got well after the discharge of a 

1 Cholecystite Purulente Provoquee par le Bacille d'Ebertb, Mem. de la 
Societe de Biologie, 1893, P- 95^- 

2 Lac. n't. 3 Traite de Med. i, 764. 
4 Munch, med. Wochen., 1897, No. 26, 699. 



THE LIVER AND THE GALL BLADDER. 251 

small sequestrum. On October 6, 1896. renewed 
attacks of colic began in the region of the gall- 
bladder. At the same time a firm tumor was dis- 
covered. By the middle of February her condition 
was still worse, with constant pain in the right hypo- 
chondrium and chills. The tumor in this region had 
now enlarged to the size of a child's head ; it was 
scarcely movable ; there was no jaundice; fluctua- 
tion was obscure ; the tenderness not marked. The 
urine showed neither albumin nor biliary coloring 
matter. Kraske made an incision over the tumor 
and evacuated 150 c.c. of brownish yellow pus not 
colored with bile. Efforts to determine the relation 
of the abscess to the gall-bladder were naturally 
very limited, on account of ' the danger of breaking 
down the adhesions, but a sound penetrated ten cm. 
upward, backward, and inward in the direction of 
the gall-bladder. No stones were felt. The patient 
made an excellent recovery. A careful examination 
seems to have been made of the pus, which showed 
unquestionably the presence of the typhoid bacillus 
in pure culture. The blood of the patient reacted 
to the Widal test in concentration of 1 to 80. 

It is greatly to be regretted, of course, that at the 
time of the necrosis of the jaw no bacteriological 
examination was made, but in view of the many 
cases already noted in this monograph, there can be 
no reasonable doubt, I think, that this w 7 as due to 
the typhoid infection. It would seem, also, that the 
repeated attacks of pain in the region of the gall- 
bladder, even though they were separated by years, 
are unquestionably to be attributed to the infection 
of the typhoid bacillus which was found at the time 
of the operation. 

It is very remarkable, indeed, that after so long a 



252 SURGERY OF TYPHOID FEVER. 

time as fourteen and a half years typhoid bacilli 
should be found in pure culture. I have not in- 
cluded the case in the table of cases of perforation 
of the gall-bladder, as it is not absolutely certain 
that it was such, though I think the probabilities 
would point distinctly in that direction. 

Chiari reported 22 cases of typhoid, in all of which 
bacteriological examinations of the contents of the 
gall-bladder were made. In 19 of the 22 he found 
the typhoid bacillus, and he concluded that the pres- 
ence of the typhoid bacillus in the gall-bladder was 
the rule. Councilman, in the discussion on Mason's 
paper, says : "I have come to regard the gall-bladder 
as one of the surest places to obtain a pure culture 
of the organism." Welch and Blackstein 1 were 
among the earliest to demonstrate the presence of 
the typhoid bacillus experimentally in the bile of a 
rabbit as long as one hundred and twenty-eight days 
after recovery from the inoculation. 

This almost constant infection of the orall-bladder 
led Chiari to suggest that very possibly it bore a 
causative relation to relapses in typhoid in this way. 
When the patient is sufficiently convalescent to be 
allowed a more generous diet, an increase in the 
quantity of food taken may arouse the liver into 
greater activity than heretofore, and the increased 
flow of bile may flood the system with numerous 
bacilli of typhoid, which may give rise to a reinfection 
causing the relapse. One would suppose that the 
condition of the blood-serum would be a protection 
against the new invasion, but in certain persons this 
seems to fail. 

1 Johns Hopkins Hospital Bull., Aug. 19, 1891, p. 121. 



THE LIVER AND THE GALL-BLADDER. 253 

While it is perfectly true, as already indicated in 
a number of cases, that Eberth's bacillus may be 
present, there are often no apparent pathological 
changes caused by its presence. It is noticeable, 
also, that Osier states that in the histories of the 
seven fatal cases in which the typhoid bacilli were 
found in the gall-bladder the infection was so latent 
that there were no hepatic symptoms observed dur- 
ing life. 

Not only may the bacilli be present in the pus, 
but also in the walls of the gall-bladder, causing 
local necrosis. Thus, Chiari J reports such a case, 
in which there were several necrotic patches on the 
walls, and the patient died from peritonitis, the direct 
result of the cholecystitis. 

Milian 2 found the typhoid bacillus itself in pure 
culture in gall-stones and in the wall of the gall- 
bladder. The case was a woman, twenty-four 
years of age, who died on the sixteenth day after 
what he calls " hypertoxic " typhoid fever. She 
had never had either hepatic colic or other symptoms 
of gall-stones, but 25 were found at the post- 
mortem. In this particular case he believes that 
the gall-stones resulted from the typhoid bacilli, 
but it seems doubtful whether within sixteen days 
25 gall-stones could have been so formed. 

Prof. Welch also informs me that he has fre- 
quently found the colon bacillus not only in the bile, 
but also in gall-stones themselves. 

Fournier, 3 in 100 cases of gall-stones removed at 
necropsies, found living or dead bacteria in the gall- 

1 Loc. cit. 2 Gaz. Hebd., Nov. 26, 1896, 1137. 

3 Origine Microbienne de la Lithiaise Biliaire, These de Paris, 1S96. 



254 SURGERY OF TYPHOID FEVER. 

stones in 38 cases. The colon bacillus was the 
most frequently found, the typhoid bacillus being 
next in frequency. He believes that an angio-cho- 
litis results either from a stasis of the bile or from its 
infection by the typhoid bacilli. This is followed by 
deposition of the salts of the bile in the form of gall-? 
stones. Possibly, even the mere presence of the 
bacilli may be provocative of the formation of gall- 
stones. Thus, Gilbert and Domenicini 1 first posi- 
tively identified the bacilli as the nucleus of gall- 
stones, and Hanot 2 confirmed this observation. 

The facts above stated make it perfectly clear, 
therefore, not only that the bacilli do reach the gall- 
bladder, and may be found in the contents of the 
gall-bladder, and even in gall-stones, but that they 
are sometimes found in its walls, and may there in- 
duce local necrosis. Not seldom, also, they proba- 
bly are the direct cause of gall-stones and the result- 
ing biliary attacks. 

Besides the bacilli of typhoid, other bacteria are 
frequently found in the gall-bladder. Letienne, 3 
out of 42 cases, found bacteria present in 24. 
These were most commonly the staphylococcus and 
the colon bacillus. 

Flexner 4 has stated that of 14 cases of typhoid in 
which the contents of the gall-bladder were exam- 
ined, typhoid bacilli were found seven times, the 
bacillus coli communis three times, the streptococcus 
pyogenes once, and the proteus vulgaris once. 

The question now arises, By what route do the 
bacilli reach the gall-bladder? Naturally, two direct 

1 Soc. de Biol., June 1 6, 1894. 2 Bull. Med., Jan. 22, 1896. 

3 Arch, de Med. Experim., 1 89 1. 4 Osier, loc. cit., p. 385. 



THE LIVER AND THE GALL-BLADDER. 255 

modes of infection are possible, and in all probability 
either or both may be assumed to be the route of 
the infection. First, the actual finding 1 of the bacilli 
in the blood itself by a number of observers (p. 58) 
suggests at once the possibility of infection through 
the circulation, and this, in Councilman's opinion, is 
the common method of infection. In addition to 
this, as the bile ducts are freely open into the intes- 
tinal canal, there would seem to be no reason why 
the infection mi^ht not be a direct retrograde one 
through their continuity. 

Through the courtesy of Dr. Mark W. Richard- 
son, of Boston, 1 am able to give the results of his 
as yet unpublished investigation bearing upon this 
point : 

"In three recent typhoid autopsies, cultivations 
from the colon, ileum, jejunum, duodenum, and gall- 
bladder were made, to see if a direct chain of bacilli, 
so to speak, could not be traced from intestine to 
gall-bladder. 

" In Case I, though the case was clinically typhoid, 
and, moreover, gave a marked typhoid serum-re- 
action, not a typhoid bacillus could be found in any 
orean. 

"In Case II there were abundant typhoid bacilli 
in the gall-bladder, but none could be obtained from 
the intestine. 

"In Case III we found pure cultures of the typhoid 
bacillus in gall-bladder, duodenum, and jejunum, and 
it was only when the ileum was reached that colon 
bacilli began to appear at all. 

"This result is quite remarkable, I think, and would 
seem to strengthen the theory of an ascending infec- 



256 SURGERY OF TYPHOID FEVER. 

tion through the gall-ducts, though, of course, it is 
perfectly conceivable that the bacilli in the duodenum 
were excreted from a eall-bladder which was infected 
originally through the blood." 

A second question requiring answer is whether 
the typhoid bacilli are capable of producing chole- 
cystitis, empyema of the gall-bladder, and ulceration 
independently of gall-stones. Of this I think there 
can be no doubt, especially in view of the facts 
above stated, and of the suppuration and ulceration 
which nearly every chapter in this book shows to be 
caused by them. Of the 74 cases of biliary infection 
in our table, in 18 cases gall-stones were found. In 
a few others, which did not come to a post-mortem, 
there may have been also gall-stones present. In 
38 cases, however, no gall-stones were present, and 
of these 8 were in persons under twenty-five years 
of age and 6 under fifteen, at which period of life it 
is extremely uncommon to find gall-stones. In 34 
of the cases reported, cholecystitis, empyema, or 
ulceration were found in the gall-bladder without 
any gall-stones, and the typhoid bacilli were identi- 
fied by bacteriological examination in 1 1 cases. 

Not only were the bacilli present, but in several 
cases, some of which have been alluded to, there 
were present such ulcers as very soon would have 
led to perforation if life had been somewhat more 
prolonged. 

Another interesting question already referred to is 
whether the typhoid bacilli of themselves give rise to 
gall-stones by producing stagnation of the bile, as has 
been suggested by Bernheim. 1 Certain it is that occa- 

1 Diet. Encyclopedique de Dechambre, 1889, Article Tctere. 



THE LIVER AND THE GALL- BLADDER. 257 

sionally biliary colic occurs cither during or after 
typhoid and suggests this possibility, as in the case 
of Chantemesse with a slow convalescence in which, 
after six months, an operation for gall-stones was 
done and a pure culture of typhoid bacilli was 
found in the ^all-bladder. 

The most important article dealing with this 
aspect of the subject is the paper of Dufourt. 1 He 
refers to 19 patients with gall-stones whose first 
attack followed typhoid fever in varying periods : in 
the second month in two cases ; the third month in 
six ; the fourth, in three ; the fifth, in one ; and 
in the other five as long as ten months or later 
after recovery. In Osier's first case, in conva- 
lescence in the fifth week after the incidence of 
the fever, the patient, who had never had hepatic 
colic, had an attack of sudden and severe pain in 
the right hypochondrium. This was followed by 
four other attacks, and though an operation did not 
reveal a gall-stone, one was discharged nearly two 
months after her last attack of biliary colic and nine 
months after her fever. This case will be referred 
to again under the heading of perforation. 

The fact also that Dr. Welch has found the colon 
bacillus and Milian and Fournier the typhoid bacillus 
in gall-stones themselves, suggests the probability 
that either or both of these bacteria may bear an 
etiological relation to the orall-stones. 

It is but reasonable to suppose that a gall-bladder 
already irritated and, it may be, inflamed by the 
presence of gall-stones, would be more likely to suf- 
fer from any invasion of the typhoid bacillus, and 

1 Rev. de Med., 1893. 



258 SURGERY OF TYPHOID FEVER. 

the very fact that in 18 cases out of the 74 of biliary 
infection gall-stones were found, makes it still more 
likely that gall-bladders containing such calculi 
readily fall victims to the ravages of the disease. 

Surgically speaking, biliary infections may be 
divided into two clinical forms : First, those in which 
cholecystitis and empyema exist with or without 
gall-stones, and, secondly, a very much more import- 
ant class, those in which perforation of the gall- 
bladder takes place. 

The symptoms in the first class of cases may be 
remarkable by their utter absence [cf. Osier, supra), 
so much so that in at least one-half of the cases of 
biliary complications the fact is wholly unsuspected. 
This is partly on account of the latency of the symp- 
toms, but also largely on account of the stupor of the 
patient. In these cases the cholecystitis and gall- 
stones are only discovered at the post-mortem. 
Ordinarily, if any symptoms are observed they will 
be, pain in the region of the gall-bladder, and the 
distended gall-bladder will be discovered both by 
touch and on percussion. The tenderness, as 
pointed out by Mayo Robson, 1 is usually at the junc- 
tion of the upper two-thirds with the lower third of 
a line drawn from the ninth rib to the umbilicus. 

As a rule, no surgical treatment can be instituted, 
but Mason's first case is a striking illustration of the 
occasional value of surgical interference. In brief, 
this is as follows : 

Case XLI. — A woman, age thirty, toward the 
end of the third week complained of pain in the 

1 Diseases of the Gall-bladder and Bile Ducts, Brit. Med. Jour., March 
13, 1897. 



THE LIVER AND THE GALL-BLADDER. 259 

right hypochondrium. A tumor four inches in dia- 
meter developed between the costal border and the 
umbilicus. The tumor was very painful, dull on per- 
cussion, and moved with respiration. A week earlier, 
when she was admitted, the liver dulness had been 
normal, and there had been no pain in this region. 
Rupture of the gall-bladder being deemed to be 
imminent, Mason at once tapped it at a point an inch 
below the costal margin and 4^ inches from the 
umbilicus. Three and a half ounces of sero-puru- 
lent fluid were withdrawn, looking more like urine 
than bile. No gall-stones were felt. The relief of 
the pain was immediate, all the urgent symptoms 
disappeared, and the patient made an excellent 
recovery. The typhoid bacilli were found in the 
fluid withdrawn. Pure cultures prepared from the 
fluid reacted to Widal's test. 

It is not often that such simple treatment will be 
followed by so happy a result, but it certainly should 
be employed in all cases of similar distention of the 
o-all-bladder. 

The following case, treated on the conservative 
plan then in vogue, also happily recovered : 

Case XLII. — Salzmann 1 reports the case of a 
woman, age forty-two, who, in the autumn of 1865, 
fell ill of a severe attack of typhoid fever, which 
involved five members of the same family. During 
the height of her illness a tumor was suddenly per- 
ceived in the abdomen between the umbilicus and 
the liver. This must have formed suddenly, as 
repeated prior examinations had not revealed it. 
When found it was the size of an orange. Its ap- 
pearance was followed very soon by an intense 
jaundice, which, however, gradually subsided, and 

1 Med. Correspondenzbl. Wlirttemburg. Arztlich. Vereins, 1S70, xl, 84. 



260 SURGERY OF TYPHOID FEVER. 

she recovered from the typhoid fever. The tumor, 
however, did not disappear. In December, 1866, 
a year after the illness, the tumor broke through 
the abdominal wall and gave exit to a considerable 
amount of clear serum. For a year after this the 
tumor gradually shrank, but left a continually dis- 
charging sinus. In 1868, two and a half years after 
the onset of the trouble, the discharge from the 
sinus increased considerably. Toward the end of 
1868 her mental condition became very bad, so that 
insanity was feared. On January 31, 1869, over 
three years after the beginning of the disease, a 
gall-stone, which was distinctly perceived in the fis- 
tula, was removed; the patient made a good re- 
covery, and five months later the fistula finally 
closed. Her mental condition, however, did not 
improve very much. 

The next case, also of operation on a distended 
gall-bladder, I owe to Professor Osier : 

Case XLIII (Osier). — " K. T., colored girl, age 
twenty-four, admitted to the medical department of 
the Johns Hopkins Hospital September 15, 1897, 
having been ill for nearly three weeks. Twenty- 
four hours after admission she had 13 stools; tem- 
perature 104 , pulse 112. 

" On September 19th it was noticed that the con- 
junctivae were a little yellow. She had complained 
of no pain, but on palpation there was great sensi- 
tiveness in the right upper quadrant of the abdomen, 
and here, just below the costal margin, a distinct mass 
was felt. Dr. Camac saw the patient in the evening 
and found the right hypochondrium very sensitive, 
and nine cm. below the costal margin and three cm. 
from the umbilicus was a rounded, resistant mass. 
This was aspirated and 15 c.c. of a clear fluid re- 
moved, examination of which showed actively motile 
rod-shaped bacilli. 



THE LIVER AND THE GALL-BLADDER. 261 

" On September 20th there was still so much ten 
derness that it was decided to operate, which was 
done by Dr. dishing-. The gall-bladder was dis- 
tended and very tense, and 1 20 c.c. of fluid were 
aspirated. A drainage-tube was inserted and the 
wound partially closed and packed with gauze. 

"The patient's condition was very bad from the 
day after admission. The temperature had been 
persistently above 105 , and on the 16th reached 
106.4 an d at the time of the tapping of the gall- 
bladder was 106 . The patient died just twenty- 
four hours after the operation. 

" The autopsy by Dr. Livingood showed character- 
istic typhoid lesions in the intestines. The gall- 
bladder contained some clotted blood ; no gall-stones. 
Typhoid bacilli were obtained in pure culture from 
the fluid removed by aspiration, from that removed 
at operation, and at autopsy. " 

The following case of doubtful etiology is of 
especial interest both surgically and bacteriolog- 
ically : 

Case XLIV. — Mark W. Richardson T reports the 
case of an elderly woman who suffered for nearly 
four weeks with fever, nausea, and considerable pain 
and tenderness in the right iliac region. This was 
thought at first to be due to appendicitis. No rose- 
spots were seen. Later there was some cough and 
rusty sputum. She had a " typhoid look." There 
was no enlargement of the spleen. After about 
two weeks a firm, rounded tumor was found at 
about the level of the iliac spine. It was tender, 
painful, and movable and extended around to the 
loin. The urine was negative. No positive diag- 
nosis was made, but it was thought, possibly, to be 
a pyo- or a hydro-nephrosis. About April 1st an 

1 Boston Med. and Surg. Jour., Dec. 16, 1897. 



262 SURGERY OF TYPHOID FEVER. 

incision was made in the back by Dr. Maurice H. 
Richardson and disclosed a normal kidney. This 
incision was closed and another was made over the 
gall-bladder, which was found to be excessively dis- 
tended. Over half a pint of dirty brownish fluid was 
evacuated. A most careful examination showed a 
pure culture of typhoid bacilli. The blood, a week 
after operation, gave no serum reaction, nor did the 
feces at the same time show any typhoid bacilli. A 
gall-stone impacted in the cystic duct was removed. 
The patient, when the case was reported, was recov- 
ering without complications. 

As to whether this was a case of typhoid fever 
followed by cholecystitis due to a typhoid infection 
of the gall-bladder, or possibly analogous to the case 
reported by Osier (see p. 48) of typhoid infection of 
the gall-bladder without typhoid fever, the fortunate 
recovery of the patient prevents a positive opinion. 

Perforation of the Gall-bladder. — Much more 
important surgically are the cases of perforation of 
the gall-bladder ; there are 30 of these in our table. 
Of these 30, four have been operated upon. This 
opens a new field in the surgery of typhoid fever 
which is of great importance and demands most care- 
ful study. The facts already stated as to the infec- 
tion of the gall-bladder, of the presence of gall- 
stones, of the presence of ulcers in the walls of the 
gall-bladder, and of necrotic areas in the wall, sug- 
gest the probability, and also the ways, in which per- 
foration may occur. 

The symptoms will be those usual in perforative 
peritonitis from any cause, such as perforation of the 
appendix, of the stomach, or of a duodenal ulcer- 
Sudden and severe pain is, of course, the most 



THE LIVER AND THE GALL-BLADDER. 263 

prominent symptom. This pain will be most intense 
in the region of the crall-bladder. If the gall-blad- 
der is much distended and perforation takes place 
toward the fundus, the seat of the most severe pain 
may be nearer to the umbilicus or in the right iliac 
fossa. In such cases it is not at all improbable that 
it would be very difficult to differentiate it from the 
perforation of the bowel from typhoid ulcer or per- 
foration of the appendix. The difficulty of making a 
differential diagnosis is of less importance than might 
appear at first sight, since in the present state of the 
surgery of typhoid fever the same treatment should 
be unquestionably instituted. Not only will there 
be severe pain, but collapse may set in very quickly. 
If the collapse be primary, partial reaction may fol- 
low. The abdomen will become distended and, 
unless the surgeon interferes, death will soon follow, 
with all the ordinary signs of perforative peritonitis. 

Of the 30 cases of perforation reported in our 
tables, 3 recovered and 27 died. 

All of those that recovered were operated upon. 

Sex. — There were: males, 11 ; females, 11, in 22 
cases in which the sex is stated. 

Age. Recovered. Died. 

Under fifteen, 9 1 8 

Fifteen to twenty-five, .5 o 5 

Over twenty-five, ... 9 2 7 

Date of onset : 

During the first week, 1 

During the second week, 3 

During the third week or later, 19 

In a small number of cases the exact time is not 



264 SURGERY OF TYPHOID FEVER. 

stated, but is given as " during the course " of the 
fever. This I have assumed to be in the third week 
or later. 

Of the cases in which perforation took place, 7 
had gall-stones and in 16 no gall-stones were found. 

Of 26 cases not operated on, every one died. 

Of 4 cases that were operated on, 3 recovered and 
1 died. 

The great mortality after perforation of the gall- 
bladder, without operation, and the fact that three 
cases out of four operated on recovered, is our 
strongest argument and best incentive to surgical 
interference in similar cases. 

As the four cases operated on are so important 
from the surgical point of view, I append a brief 
resume of each. 

Operation. — The operation for peritonitis follow- 
ing perforation of the gall-bladder differs in no 
material respect from the operation for perforation 
of the bowel, and I will refer the reader, therefore, to 
Chapter XV for the principal points. Two others 
need some consideration. 

First, the incision. The best line of incision is 
over the tumor, if there be one ; if not, then at the 
outer border of the right rectus muscle. In case the 
gall-bladder is distended toward the median line, a 
median incision may be best. In three of the four 
cases operated on the incisions were respectively: 
in the median line ; parallel with the ribs ; and the 
incision for appendicitis : the exact incision in the 
fourth case is not stated. 

The only other peculiarity, perhaps, that I need men- 
tion is the method of dealing with the gall-bladder 



THE LIVER AND TH E GALL-BLADDER. 265 

itself. If the walls of the gall-bladder in the neighbor- 
hood of the perforation allow of it, one or two rows of 
Lembert sutures, inverting the peritoneal coat, is the 
best method of repairing the perforation. Should 
this not be possible, then the best plan would be cir- 
cular packing around the opening with iodoform 
Bfauze, so as to form a defensive wall for the. 
abdominal viscera, leaving in the center a sort of 
well leading down to the perforation. This should 
be separately packed. The incision should never be 
entirely closed, drainage being essential. 

The prognosis in perforation of the gall-bladder, as 
distinguished from perforation of the bowel, is cer- 
tainly very much more encouraging, if we may draw 
any inferences from so small a number of cases. 
This would naturally be the case, since the contents 
of the gall-bladder are less irritating than those of 
the intestine. 

I append a resume of each of the four cases ot 
perforation of the gall-bladder which have been sub- 
mitted to operation. 

Case XLV (Williams and Sheild 1 ). — "This care- 
fully studied and admirably reported case should 
be read in full. A woman, thirty-one years of age, 
was first seen by Mr. Monier-Williams, September 
18, 1894, her illness having begun on September 
13th. The spleen was enlarged. There was 
some tenderness in the right iliac fossa, but no 
abdominal pain. September 23d, the eleventh day 
of the disease, she was seized early in the morning 
with sudden acute abdominal pain. Mr. Williams 
' found her in a semi-collapsed condition, with feeble, 
fluttering pulse and cold, clammy skin, complaining 

1 Lancet, 1895, i, 534. 



266 SURGERY OF TYPHOID FEVER. 

of pain in the abdomen. The temperature shortly 
before the commencement of the pain was 102. 5 , 
but two hours later had fallen to 99 . Abdominal 
breathing was practically absent. The pain was 
diffused over the upper part of the abdomen, a spot 
a little above the umbilicus being, perhaps, the seat 
of its greatest intensity, and there was considerable 
tenderness over the region of the ascending colon. 
A possible perforation of the intestine was con- 
sidered even at this early date. Opium was ordered 
and all food by the mouth stopped. Twelve hours 
after the collapse the temperature rose to 104.5 . 
In a few days all pain and tenderness had dis- 
appeared. By October 28th she was practically 
convalescent ; the abdomen was natural in every 
respect. On the night of the 29th she had some 
slight abdominal pain, but not enough to keep her 
awake. On the morning of the 30th, however, 
she was suffering severe pain, which was referred 
to the region of the hepatic flexure of the colon, 
and there was considerable tenderness in this 
region ; an area about the size of an orange became 
decidedly dull on percussion and very tender. In- 
testinal perforation was then again considered. 
The next morning, October 31st, the patient was 
much worse, with decided distention of the abdomen 
and signs of recurrent peritonitis in the right 
hypochondrium. On the 31st Mr. Sheild first saw 
her with Mr. Monier-Williams. Along with the 
symptoms already described, it is noted that ' the 
extremities were not cold, the tongue was clean, 
and the patient was rational and could converse. 
The face was pinched and anxious, but lacked the 
appearance of death-like collapse so noticeable in 
perforation of the intestine from typhoid ulceration. 
By the next day, November 1st, operation was 
determined upon, as the abdominal conditions were 
worse, though her general condition had improved. 



THE LIVER AND THE GALL-BLADDER. 267 

A free incision was made in the median line above 
the umbilicus. The intestines were distended, 
red, congested, and covered with purulent lymph. 
Believing that a perforation existed toward the 
upper part of the intestinal canal, diligent search 
was made, but none could be detected, and while 
disentangling the adhesions and sponging away the 
soft lymph under the liver, the gall-bladder came 
into view, and its appearance was peculiar and sug- 
gestive. This viscus was deeply inflamed, of a dark 
plum color, rigid, thickened, and adherent, but not 
much enlarged, though tightly distended. The 
source of mischief was soon apparent, for low down 
near the neck of the gall-bladder was a sharply 
circular sloughing ulcer, the size of a three-penny 
piece. Its floor was bright yellow and it was sur- 
rounded by a vivid red zone of intense hyperemia. 
On stroking it with the probe, fluid escaped at one 
point, showing that leakage of the contents had 
already occurred. The gall-bladder was opened at 
its fundus, evacuating f^iss of thick offensive pus 
not mixed with bile. Careful search for a calculus 
was made, but none could be detected. The slough- 
ing ulcer near the neck of the gall-bladder had now 
quite given way, and I [Mr. Sheild] tried to unite 
it after the Lembert method, but the stitches cut 
their way out persistently, though deeply placed. It 
was obvious that the gall-bladder was too soft and 
lacerable to deal with, still less to bring it to the 
surface of the abdominal wound. The wound in 
the fundus was, therefore, attached to the parietal 
peritoneum and the parts under the liver cleansed 
by flushing with warm water and repeated sponging. 
A second incision was made at right angles to the 
former, reaching toward the right lower ribs to 
allow of more drainage. The intestine was relieved 
of flatus by puncture ; a glass drainage-tube was 
now inserted, and a long and liberal slip of carbol- 



268 SURGERY OF TYPHOID FEVER. 

ized gauze packed firmly around it, so as to flatten 
the empty gall-bladder against the surface of the 
liver and shut off the intestine from contact. The 
rest of the abdominal wound was closed. The 
operation lasted an hour. The patient was fed by 
the rectum ; a saline purge was given two days after 
the operation. On the sixth day a purulent dis- 
charge was observed from the tube ; no bile escaped. 
After this the patient made a very excellent re- 
covery.' " 

Case XL VI (Alexieef 1 ). — "A girl, age five, was 
taken, November 5th, with parotitis, which suppurated 
on the left side. By the 29th the spleen was en- 
larged. The patient passed through a severe attack 
of typhoid fever. ' During the second week in De- 
cember the patient became very drowsy and was 
delirious; there was tenderness in the ileocecal re- 
gion. The rales at the bases more numerous ; con- 
siderable expectoration ; the roseola diminished, but 
was still present. During the third week in Decem- 
ber the patient became markedly worse, complaining 
of pain, especially in the right side of the abdomen. 
When lying on her back there was to be made out, 
four or five fingers' breadth below the costal margin 
on the right side, a rounded tumor about half the 
size of a small hen's egg. On percussion the tumor 
was pear-shaped, and the dulness was continuous 
with that of the liver. There was marked motion 
with respiration ; it was elastic and somewhat tender 
on palpation. Distinct fremitus was found to be 
present on palpation between the 1 8th and 20th. 
Diarrhea. The urine by this time had begun to 
contain a trace of albumin. On the nights of the 
20th and 2 2d the patient became much worse, com- 
plaining of great abdominal pain. Finally she be- 
came greatly excited ; jumped out of bed ; did not 

1 Jour. Dietskava Meditzina, 1896, No. 4, in the Amer. Jour, of the 
Med. Sciences, Oct., 1897, p. 466. 



THE LIVER AND THE GALL-BLADDER. 269 

recognize those about her ; and became very feeble 
and collapsed. Temperature, 36. 6° C. ; pulse un- 
countable. Tinct. valer. aeth. was given hypoder- 
matically ; by the following morning she became 
somewhat calmer. At this time the tumor, which 
had been palpable the day before, was no longer to 
be made out. The abdomen was much distended 
and tender. The bowels moved only by enema. 

" ' On the 25th patient was worse, complaining of 
severe pain in the right side ; abdomen much dis- 
tended ; everywhere tender. Cries out with pain. 
There is no jaundice. From the 29th to the 31st 
the temperature was somewhat lower, but the patient 
seemed much worse ; lies on her back or on the 
right side, with the knees drawn up ; can take no 
other position. The abdomen, especially on the 
right side, is distended and very tender. The out- 
lines of the tumor, which were formerly made out, 
are not to be distinguished. 

" ' A diagnosis of cholecystitis or suppuration in 
the neighborhood of the gall-bladder was made, and 
operation advised. This was performed on the 31st, 
an incision nine cm. long, parallel to and two fingers 
below the costal margin on the right side, being 
made. On opening the abdominal cavity a serous 
fluid, colored with bile, escaped. The intestines 
were adherent ; there was pus in the gall-bladder 
and surrounding it, suppuration having extended 
also into the pregastric area. The pus was emptied, 
drainage established, and the cavity packed with 
iodoform gauze. After the operation the patient 
was excessively weak, and 20 c.c. of salt solution 
were introduced hypodermatically.' The patient 
made an excellent recovery. On February 9th, 
however, a relapse occurred, from which she recov- 
ered by the 21st. During all this time the discharge 
in the healing wound had gone on satisfactorily. 
The discharge consisted of bile, mixed at times with 



270 SURGERY OF TYPHOID FEVER. 

a little pus. The discharge stopped by the 24th 
and the spleen was no longer palpable. A slight 
attack of pneumonia occurred from March 13th to 
17th, but by March 26th she was entirely well. 
Careful cultures from the pus showed pure typhoid 
bacilli. 

Case XL VII (Osier x ). — "A woman, age twenty- 
nine, was admitted to the Johns Hopkins Hospital, 
April 22, 1895, on the fourth or fifth day of typhoid. 
She passed through a period of pyrexia of twenty- 
seven days' duration. 'On May 2 2d she had an 
attack of sudden severe pain in the right hypochon- 
driac region. The temperature rose to 102 , without 
a chill, and she had fever for thirty-six hours. There 
was no jaundice. Some time after she left the hos- 
pital, on June 21st, she had a second severe attack 
of pain in the same region, of great intensity. It was 
also not followed by jaundice. During the summer 
she had two other attacks, each lasting about eighteen 
hours, but without jaundice. She apparently had re- 
covered entirely, when at noon on December 23d she 
vomited, and later in the day had an attack of very 
sharp and severe pain in the right iliac fossa. The 
pain came on in paroxysms lasting for a minute or 
more. The abdomen was flat, but over the entire 
right side there was muscular rigidity and a great deal 
of tenderness. The pain was localized in a small 
area close to McBurney's point. Any palpation in 
that region was very tender. Pressure on the left 
side of the abdomen caused a dragging sensation 
and pain between the navel and the anterior superior 
spine. The next day she had recurring attacks of 
pain over the whole right side.' A diagnosis was 
made by both Osier and Halsted of appendicitis. 
She became so much worse that at six o'clock the 
same evening Dr. Halsted operated. 'An incision 
was made for appendicitis. There were a few old 

1 Trans. Assoc. American Physicians, 1897, xii, 388. 



THE LIVER AND THE GALL-BLADDER. 2J I 

hands of adhesion seen about the cecum, but the 
appendix was not found, and it was evident that the 
seat of the trouble was not here. Just above the 
cecum the omentum was seen, adherent to the as- 
cending- and the hepatic flexures of the colon. In it 
was a small opening- from which a thin yellow mate- 
rial flowed. At first this was thought to be perfora- 
tion of the intestine in an old typhoid ulcer, but on 
enlarging the incision the opening was found in the 
gall-bladder, to which the omentum was adherent, 
and in the adhesions between the liver and colon 
there were several small pockets containing purulent 
yellowish material. The gall-bladder was enlarged 
and very tense ; ioo c.c. of a clear fluid were re- 
moved, after which about 30 c.c. of thick purulent 
matter flowed out. The cystic and common ducts 
were explored, and it was thought that a stone was 
felt in the cystic duct, but on account of the depth of 
the duct and the numerous adhesions, and the 
difficulty of preventing infection of the peritoneal 
cavity, the gall-bladder was packed with gauze and 
the opening about it closed. 

"'The patient did very well. On February 1st, 
upon introducing a probe into the sinus, a stone was 
felt, which gradually came out. She was discharged 
February 19th, and has remained well ever since.' ' 

Case XL VIII (Osier 1 ).— "November 5, 1894, he 
saw a woman, age thirty-seven, at the end of the third 
week of a very severe attack of typhoid. The 
attack was very protracted and she was in bed nearly 
ten weeks. On January 1, 1895, she had been at- 
tacked suddenly with severe pain in the epigastrium, 
passing round the right side to the back. She had 
no chill. On the fifth day after the onset she be- 
came jaundiced. On January 21st she had a severe 
chill; on the 27th the temperature rose to nearly 
105 , and she had nausea and vomiting. The abdo- 

1 Loc. cit., p. 390. 



272 SURGERY OF TYPHOID FEVER. 

men was distended and so tender that it was impos- 
sible to make a satisfactory examination. Dr. Hal- 
sted performed laparotomy on the 29th. 

" ' The surgical note states that on opening the 
abdomen the liver was seen to be enlarged, the gall- 
bladder projected below the right margin, and on its 
anterior wall a rupture was seen through which bile 
and purulent matter were oozing. The wall of the 
gall-bladder in the neighborhood was quite necrotic. 
The gall-bladder was incised, drained, and packed. 

"'Cultures were made from the contents of the 
gall-bladder, and the colon bacillus was found. The 
colonies were worked over with the greatest care 
with reference to the differentiation of the typhoid 
from the colon bacillus. 

" ' The temperature fell after the operation and be- 
came normal on February 1st. She did very well 
for ten or twelve days ; then she began to have nau- 
sea and vomiting, with marked reduction in the 
amount of the urine. There was no change in the 
jaundice, and she sank and died on February 21st' " 



UJ 
> 

UJ 

u- 

Q 

O 
X 

CL 
>- 

H 

C* 
UJ 


bd 

s 

(5 


See original paper for exact 
and valuable report, and page 
265 for a full resumed 

Tumor in region of gall-blad- 
der. Symptoms of perforation. 
Cholecystitis and e m p y e in a 
found at operation. No stones. 
Bacilli of Ebertfa in pus. Re- 
lapse in 1 2th week. Perma- 
nent recovery without fistula. 

She had 5 attacks of pain in 
the region of the gall-bladder ; 
the first in the 5th week of her 

typhoid fever. 


cd _ 

5-E 

g 


< 

UJ 
Q 

Q 
< 
J 

CQ 

J] 

-J 
< 

O 

UJ 
X 

o 

z 

O 


'j/ins i>[ 

•NOIJ. 

-VM3.1() 
Mil' 1 

ivA.xai.Ni 


06 06 '2 


Q 


U ncer- 
tain ; prob- 
a b 1 y 2 
days. 

18 hours. 


a 

. 


Operation. 


Suppuration in gall-bladder. 
Intestines punctured to relieve 
flatus. Drainage and packing. 

Laparotomy. Packed and 

drained. 

Operation for appendicitis. 
Omentum adherent to colon. 
Several small abscesses between 
liver and colon. One hundred 
c.c. clear fluid and 30 c.c. pus 
evacuated from gall-bladder. 
Stone possibly felt and spon- 
taneously discharged 6 weeks 


later. 

Laparotomy. Liver enlarged. 
Gall-bladder ruptured ; its walls 
necrotic. Contents purulent. 
Incision, drainage, and packing. 


< 

o 

U- 

C£ 
UJ 

a. 
O 

tin 

z 

o 

a: 

UJ 
CL 

O 

EL 

o 

CO 

UJ 
GO 

< 

U 

| 


Date of 
Occurrence. 


Eleventh 

day. 

About fifth 
week. 

Eight months 
after the fever. 


15 weeks 
after fever be- 
gan. 


z 

o 

P 
< 
u 

o 


Near base of 
gall-bladder. 

Perforation of 

gall-bladder. 

Perforation of 
gall-bladder. 


R up lure of 
gall-bladder. 


•X3S 
*30V 


M IT) O 

ro <N 


ro 


Reference. 


Lancet, 1895, i, 
534- 

Jour. Dietskaya 
Meditzina, in Am. 
Jour. Med. Sci., 
Oct., 1897, p. 466. 

Trans. Assoc. 
Amer. Phys., 1897, 
xii, 388. 


Trans. Assoc. 
Amer. Phys., 1897, 
xii, 388. 


UJ 

-J 

CQ 
< 


Reporter. 


[l] Williams 
and Sheild. 

[2] Alexieef. 

[3] Osier and 

Ilalsted. 





18 



273 



CHAPTER XVII. 
TYPHOID AFFECTIONS OF THE SPLEEN. 

Among the most constant places in which the 
typhoid bacilli are found are the bone-marrow and 
the spleen. On page 30 I have given a list of a 
number of authors who have found them in the 
spleen. 

It was, therefore, rather a surprise to me that I 
was only able to cull from my second table of over 
800 cases (there were none in my former series) 
only nine cases of abscess of the spleen ; indeed, 
strictly speaking, only eight, for one of them was an 
abscess "about" the spleen. But as the bacillus of 
Eberth was found in it, and the spleen is so com- 
monly invaded by the typhoid bacillus, it is reason- 
able to suppose that the spleen was at least its 
origin. There were also miliary abscesses in the 
kidney. In one case * the abscess ruptured, produc- 
ing a fatal peritonitis. In two cases there was mitral 
disease, one 2 from an old rheumatism; the other 3 
probably originated during the typhoid attack, as the 
bacilli of Eberth were found in the mitral vegetations. 
In this case there was also cerebral meningitis. Both 
of these cases may easily have been embolic in origin. 
One case 4 was complicated with gangrene of the 

1 Flavio, Gaz. degli Ospit., in Dublin Jour. Med. Sci., Nov., 1890,445. 

2 Dunin, Univ. Med. Mag., Sept., 1895, 9°9- 

3 Vincent, Merc. Med., Feb. 17, 1892, 73. 

4 Griesinger, Infect. Krankh., Virchow's Handb. Pathol., 1857. 

274 



TYPHOID AFFECTIONS OF THE SPLEEN. 275 

lung-, and another 1 with suppuration in the thyroid. 
One case arose "in the course" of the disease, four 
about the third week, and four as late sequels — three 
of them arising" as late as the seventh and eighth 
week. 

Every case proved fatal, as, in fact, would be 
expected. Three were only discovered at the ne- 
cropsy, one (Flavio) having been overlooked in con- 
sequence of a left pleuro-pneumonia with effusion. 
If discovered and recognized, the only possible 
remedy would be a celiotomy — a desperate remedy ; 
in most cases, probably, not even to be considered. 

Six were males and three females. 

The following case of leukemic spleen under my 
care seems to have resulted from typhoid : 

Case XLIX. — Mrs. S. T., of Hamburg, Pa., was 
admitted to the Jefferson Hospital April 7, 1896, at 
the instance of Dr. Nice. She is a widow, age thirty- 
one. Both parents and six brothers and sisters are 
living and in good health. Three brothers and 
sisters died in infancy. Her menstruation began at 
fifteen, and has always been regular. She had a 
still-born child at eighteen, was married at twenty- 
seven, and has had one miscarriage since. Had 
influenza in March, 1893, when she was in bed for 
three weeks. In November, 1894, she had a severe 
attack of typhoid fever, confining her to bed for four 
months. During convalescence she complained of 
a severe, constant pain in the left lumbar region, with 
a point of great tenderness midway between the 
anterior superior spine and the costal cartilages of 
the tenth and eleventh ribs on the left side. She 
was unable to lie on the left side on account of the 
pain. She also had repeated irregular chills — some- 

1 Griesinger, loc. cit. 



276 



SURGERY OF TYPHOID FEVER. 



times one to three a day ; occasionally a day or two 
passed without any. There were also profuse 
sweats, most frequent at night, but without any 
cough or expectoration. She has never been able 
to walk since her typhoid fever. Her abdomen 
began to enlarge soon after the fever, and has 
steadily increased in size to the present time. On 
admission her temperature was 102. 4 , pulse 113, 
respiration 32. She looked very pale ; her appetite 




Fig. 4. — Area of tumor in Case XLIX. 



was good ; the abdomen was greatly distended by a 
large tumor, the area of which is marked in figure 
4. It extended from the ribs to the brim of the 
pelvis, filled the entire left side of the abdomen, and 
reached to within an inch of the anterior superior 
spine of the ilium on the right side. About an inch 
above the level of the umbilicus was a notch on the 
right border of the tumor, and one at a lower level 
on the left border. Change of posture does not 
change the position of the tumor. Its right edge is 



TYPHOID AFFECTIONS OF THE SPLEEN. 277 

wedge-shaped. The surface of the tumor is smooth, 
regular, with firm resistance. The left costal carti- 
lages are distinctly bulged forward by it, and there 
are no adhesions to the belly wall. 

Dr. Kyle examined the blood and made the fol- 
lowing report : 

Hemoglobin, 45 per cent, of normal. 

Red corpuscles, per cubic millimeter, total 2,720,000. 

Red corpuscles, per cubic millimeter, normal, 2,500,000. 

White corpuscles, per cubic millimeter, 336,000. 

The appearance of the red corpuscles under the microscope was 
practically normal. A few were small (microcytes) and some 
slightly irregular in outline. 

Of the leucocytes, many were granular and degenerating, some 
almost dividing. There were many large granular lympho- 
cytes present. No malarial organisms. No typhoid bacilli. 

As the case was one of leukemic spleen, I decided 
not to operate, and she was discharged April 17, 
1896. 

Dr. Nice writes me that she died on May 29, 1897, 
Nothing beyond the enlargement of the spleen was 
found at the post-mortem. Unfortunately, no oppor- 
tunity was afforded for a bacteriological examina- 
tion. 

On page 163 I have given a resume of a case of 
subdiaphragmatic abscess supposed to have arisen 
from the spleen. 



CHAPTER XVIII. 

TYPHOID AFFECTIONS OF THE SEXUAL ORGANS. 

I. The Male Sexual Organs. — Very rarely the 
male genitals are attacked by gangrene (see p. 78). 
Janzion z has recorded a case of " malignant or ataxic 
fever " (typhoid ?) in which priapism was the princi- 
pal symptom. Andrew 2 has recorded a case of 
abscess of the prostate. One of my medical friends 
tells me that in convalescence from typhoid fever 
when a boy, he suffered from an attack of urethritis 
not due to the use of the catheter. 

Case L. — Dr. A., at the age of fifteen, had an 
attack of typhoid fever followed by a relapse. No 
catheter was ever used. In the early part of conva- 
lescence a series of boils broke out over the body. 
A muco-purulent urethral discharge, with scalding 
following micturition, set in about the same time ; 
there was no severe pain, no swelling of the meatus. 
The urethritis continued for about a week or ten 
days and then subsided spontaneously. Later in 
the convalescence the right testicle swelled some- 
what and became a little tender. Though the swell- 
ing abated, this testicle has always remained some- 
what larger than the other. 

I only know of a single other published case of 
urethritis following typhoid fever 3 : 

Case LI. — The patient was a soldier, who, after 

1 Ann. Soc. de Med. de Montpellier, lv, i, 146. 2 Lancet, 1871, ii, 712. 
3 Legrain, Annales des Organes Genito-Urinaires, 1889, vii, 291. 

278 



THE SEXUAL ORGANS. 2J$ 

typhoid, in the third week of convalescence, was 
attacked with urethritis. He had never had any 
venereal affection. For several days there was 
pain in urination, and later considerable discharge 
from the urethra, which became bloody. It was 
followed by cystitis of short duration. His recovery 
without treatment was complete at the end of three 
weeks. Bacteriological examination showed in the 
discharee numerous cultures of various micrococci, 
especially the staphylococcus pyogenes aureus, but 
no typhoid bacilli or gonococci. Legrain himself 
attributed this unusual urethritis to a possible ne- 
crosis of the urethral mucous membrane analogous 
to localized gangrene elsewhere. 

The most frequent typhoid lesions are orchitis and 
epididymitis. It is somewhat strange that in the 
careful and extensive search through typhoid litera- 
ture prior to 1876, 1 did not find a single case involv- 
ing the testicle. In 1844, Velpeau, 1 however, I find, 
alluded to typhoid orchitis. Dr. Westcott has col- 
lected 32 cases, of which two had been reported 
prior to that date, but not found by myself. 

The typhoid bacillus has been found in the testicle 
during typhoid fever, not only when it was not in- 
flamed, 2 but has now been repeatedly found both in 
orchitis and epididymitis, and not only in the pus, but 
in the tissues. Gasser, 3 in a case of orchitis without 
suppuration, by an antiseptic puncture obtained a 
drop of fluid in which numerous typhoid bacilli were 
found. After recovery the testicle remained indu- 
rated. In Girode's case 4 of epididymitis, at the 
necropsy the suppuration was found to be intersti- 

1 Diet. En Trente Vol., Art. Testicule. 2 Dehu, ioc. a't., p. 82. 

3 Archiv de Med. et de Pharm. Milit., 1895, No. 3, 228. 

4 Arch. Gen., 1892, clxix, 43. 



280 SURGERY OF TYPHOID FEVER. 

tial and outside the canaliculi. A pure culture of 
the typhoid bacillus was found in the pus. The tes- 
ticle was not involved. Though he was twenty- 
nine years of age, no spermatozoids were found, at 
least in the epididymis. 

Tavel x reports a case of suppurative orchitis in 
which the typhoid bacillus was found in pure culture 
in the pus. 

Menetrier 2 reports a similar case. In both of these 
cases the epididymis escaped. 

The date of onset, also, is a presumption that most 
of the cases were not due to a mixed infection by the 
pyogenic bacteria, but by the typhoid infection itself, 
for of 29 cases only a single one arose in the second 
week, seven in the third, and 21 occurred in convales- 
cence — i. <?., after the third week. The marked ten- 
dency of almost all of the pure typhoid infections 
toward a late origin seems, therefore, to hold here 
also. One case was probably septic, 3 in which a paro- 
titis arose on the fourteenth day and was followed six 
days later by orchitis, in a boy of four. It is not at all 
impossible, as Widal thinks, 4 that some of the cases 
may arise from thrombosis of the spermatic veins — 
an opinion, however, which was put forth prior to 
the discovery of the typhoid bacillus. Girode sug- 
gests that the typhoid bacilli gain access to the epi- 
didymis and the testicle from the urine. It is well 
known that the typhoid bacillus is often found in the 
urine (p. 32), and it is possible that this may be its 

1 Correspondenzbl. schweiz. Aerzte, 1887, 590. 

2 Pein, These de Paris, 1890, 18. 

3 Bouclmt, Mai. des Nouveaux Nes, 1867. 

4 Pull. Soc. Clinique, Paris, 1877, i, 142. 



THE SEXUAL ORGANS. 28 I 

source, but the wide diffusion of infection through 
the blood (p. 23) seems to me to make it far more 
likely that the latter is its source. In Girode's own 
case the typhoid bacilli were not found in the sem- 
inal canaliculi (as would have been most probably 
the case had they come from the urinary passages) 
but in the inter-canalicular tissues. 

The infection may be confined to the epididymis 
alone (4 cases), to the testicle alone (15 cases), or, 
as happened in 6 cases, both may be involved. The 
right side was involved 1 1 times, the left 9, and in 
one instance both sides. 

Age.— 

Under fifteen there were 2 cases. 

From fifteen to twenty-five there were 11 " 
Over twenty-five there were 10 il 

23 cases. 

Date of Onset. — This occurred — 

In the second week in 1 case. 

" third week in 7 cases. 

" fourth week in 3 " 

" fifth and sixth weeks in . . . .• 8 " 
" seventh week and later .... 10 " 

29 cases. 

The symptoms need no special description, except 
to call attention to the fact that the disease, especi- 
ally in the epididymis, is often apyretic. Like lesions 
of the bones, where the infection is not mixed, but 
from the typhoid bacillus alone, the disease is local, 
and does not ordinarily, therefore, cause much con- 
stitutional disturbance. 

The termination of the infection is in most cases 



2*82 SURGERY OF TYPHOID FEVER. 

by resolution. This is expressly stated in 16 of the 

cases, and it probably followed in others. In the 

epididymis suppuration arose only once. When 

suppuration occurs in the testicle itself, its effects are 

apt to be more serious. This took place five times, 

and in three of them the slouching was so exten- 
ts t> 

sive that practically the entire testicle was destroyed. 

The mortality was small ; only one case certainly 
died, 1 and in this death was the result not of the 
disease of the testicle, but of the lungs. I n another 
the result is not stated ; 2 but as it was probably 
septic, in a child of four, parotitis occurring on the 
fourteenth day and orchitis on the twentieth, it is 
doubtful whether so young a patient would survive 
the continued influence of the fever and these two 
early and probably septic complications. 

II. The Female Sexual Organs. — In view of 
the occasional involvement of the testicle, it is strange 
that so few cases of pure typhoid abscess or other 
typhoid lesion of the ovary should have been re- 
corded. Yet it has not wholly escaped the indirect 
malign influence of this upas-like fever. 

Case LII. — Thus, Anger 3 has recorded the case 
of a woman, age thirty-three, who died, twenty hours 
after entrance into hospital, from typhoid of unstated 
duration. At the necropsy slight traction on an ad- 
hesion of a coil of intestine to the bladder at one of 
Peyer's patches tore a hole in the bladder at the site 
of a vesical ulcer. There were also abscesses in 
each broad ligament, due to a perforation of the 
rectum from ulceration. 

1 Girode, Arch. Gen., 1892, i, 43. 2 Bouchut, vide ante. 

3 Bull. Soc. Anat., 1865, 364. 



THE SI 'IX UAL ORGANS. 283 

Werth ' describes the following case, in which an 
old dermoid cyst of the ovary suppu rated eight 
months after the fever. Fortunately, a bacteriologi- 
cal examination was made, or the influence of the 
fever might well have been questioned. In the pus 
a pure culture of the typhoid bacillus was found. 
She recovered after operation. 

Case LIU. — A woman, age twenty-nine, entered 
the hospital June 2, 1892, on account of an enlarge- 
ment of the abdomen and pain in its right lower 
quadrant. The pain had suddenly seized her at the 
beginning of the year, while she was working, and 
had recurred at shorter or longer intervals ever 
since, later becoming more persistent and some- 
times very severe. Soon after the beginning of the 
pain the patient observed that the abdomen was 
swollen, and in October and November, 1891, — that 
is to say, about eight months prior to her entering the 
hospital, — she had an attack of typhoid fever which, 
as was ascertained from her physician, was of mode- 
rate severity and without complications. On entering 
the hospital her abdomen was markedly distended 
by a tumor which plainly fluctuated. It was moder- 
ately movable and somewhat painful. The greatest 
circumference of the abdomen over the middle of 
the tumor was 78.5 cm. It rose 21 cm. above the 
symphysis. The uterus lay behind it. Operation 
June 4, 1892. The tumor was removed with some 
difficulty on account of adhesions, but the operation 
was finally successfully accomplished. The wall tore 
during removal, and some masses of fat, in which 
were a number of dark hairs, escaped. The tumor 
originated in the left ovary. The right ovary had 
a cyst as large as a lemon. This was opened with 
scissors and the wound was sutured. Bacterio- 

1 Deutsch. med. Wochen. , 1893, No. 21. 



284 SURGERY OF TYPHOID FEVER. 

logically the pus from the tumor showed a pure 
culture of the typhoid bacillus. 

Case LIV. — Sudeck 1 reports the following similar 
case : A woman, age thirty-two, a widow for eleven 
years, suffered for several years with pain in the 
lower abdomen, dysuria, and constipation. Seven 
weeks before entering the hospital she fell ill with 
typhoid fever. Three weeks before her entrance 
into the hospital she noticed that the abdomen was 
swollen, and she had again pains in the abdomen and 
difficulty in passing water. On the 5th of Novem- 
ber, 1895, when first seen, a marked tumor was found 
in the hypogastrium, extending into the pelvis, and to 
a little above the navel ; fluctuation was uncertain. 
The uterus was anteflexed, lay somewhat to the left, 
and moved with the tumor. The cavity of the uterus 
was seven cm. long. Hectic fever set in and the 
diagnosis of a suppurating ovarian tumor was made. 
On the 1 ith of November Dr. Sick operated. The 
tumor was in the right ovary and was as large as the 
head of a ten-year-old child. It was removed with- 
out difficulty. The walls were about one cm. thick. 
The contents were a thick pus and fibrin with choco- 
late-colored fluid, smelling very badly. No bacteria 
could be found by the microscope. Cultures were 
made and the typhoid bacilli were recognized in 
pure culture. In the wall of the cyst were found 
some diplococci. The patient made an excellent 
recovery. 

Case LV. — Pit'ha 2 reports a third case of sup- 
puration in a dermoid cyst in which a pure culture 
of the typhoid bacillus was found. He attributes 
the suppuration entirely to the bacillus of Eberth. 
The patient was a woman twenty-five years of age. 
She was admitted to the hospital on February 6, 
1897. Two years before he saw her she had suffered 

1 Munch, med. Wochen., 1896, No. 21, 498. 

2 Central bl. f. Gynekologie, 1897, No. 37, p. 1 109. 



THh] SEXUAL ORGANS. 2.S5 

from chlorosis, during which time her menstruation 
ceased for a year and a half. Four months prior to 
her admission she fell ill with typhoid and was in 
bed for four weeks. In the fifth week she observed 
on the right side of the lower abdomen a painful 
tumor without definite limits. Gradually it became 
well delimited. Her menstruation had not returned 
since her sickness ; appetite was poor ; bowels irregu- 
lar. She was evidently a poorly developed woman. 
In the lower half of the abdomen was a tumor which 
reached up to the navel, and, especially at the sides, 
showed fluctuation. It was not movable, and caused 
but little pain. A vaginal examination showed that 
the tumor pushed the posterior vaginal wall mark- 
edly forward, and the uterus was lifted and pressed 
against the symphysis, being covered by the bladder, 
which last reached half way to the % navel. Examina- 
tion by the rectum showed that the whole pelvis was 
filled with the tumor, that the recto-vaginal septum 
was pushed downward, and both the vaginal and the 
rectal wall arched. The rectal wall, however, was 
movable over the tumor. On the right side the 
tumor was connected with the bones of the pelvis 
by a hard, tender, solid mass. Otherwise the lower 
part of the tumor was elastic and fluctuating. Opera- 
tion was done February 21, 1897. Some of the fluid 
was removed by a puncture and immediately exam- 
ined microscopically. A great mass of polynucleated 
pus-cells in degenerative stages was found, but no 
micro-organisms. Accordingly, the tumor was 
opened through the posterior wall of the vagina by 
the thermo-cautery, evacuating three liters of pus, 
in which also were some hairs, making certain the 
diagnosis of a suppurating dermoid cyst. Examina- 
tion with the finger showed that it was a multilocu- 
lar cyst, and that vaginal extirpation would not be 
advisable, especially on account of its adhesions. It 
was, therefore, thoroughly washed out and the vagina 



286 SURGERY OF TYPHOID FEVER. 

tamponed with iodoform gauze. Laparotomy was 
immediately done. The bladder reached a hand- 
breadth above the symphysis ; the uterus was small ; 
the dermoid cyst arose from the right ovary. There 
were some adhesions to the intestine, which were 
broken up by blunt dissection, but it was not possible 
to lift the tumor until the adhesions on the right side 
of the pelvis were broken up, which required con- 
siderable force. The pedicle was divided by the 
Paquelin cautery ; the pelvis cleansed with sterile 
compresses ; the raw surface of the pelvic adhesions 
were covered by a peritoneal flap from the right 
broad ligament. The left ovary was small. The 
opening in the vagina was closed with catgut and 
the abdomen entirely closed without drainage. Ex- 
amination of the. extirpated cyst showed that necrotic 
processes had begun at several points. Both bones 
and cartilage, as well as a considerable amount of 
black hair, were found in the tumor. The patient 
made an uninterrupted recovery. No micro-organ- 
isms whatever were found microscopically in the pus. 
The contents seemed to be chiefly disintegrated 
epithelial cells and polynucleated pus-cells. Cultures, 
however, were made which showed pure typhoid 
bacilli, both by morphological and biological tests 
and also by their reaction to Widal's serum test. 

The conclusion of the author, therefore, was that 
the typhoid bacilli were the direct cause of the sup- 
puration, and that they were present, as shown by 
the culture, four months after the fever. 

Mabit 1 records a case of pyosalpinx, which, unfor- 
tunately, like that of Anger which occurred in 1865, 
has no bacteriological proof of its typhoid origin, and 
the remote date of its discovery and possibilities of 
intervening causes make it doubtful. A young 

1 Nouvelles Archives d'Obstet. et de la Gynecol., 1893, viii, 267. 



THE SEXUAL ORGANS. 287 

woman of nineteen, when convalescent, developed 
recurring pains in the left side of the abdomen, with 
amenorrhea. She married at twenty-one, and at 
twenty-nine was cured of a left pyosalpinx by dilat- 
ing and tamponing the uterus. 

It is beyond the object of this monograph to con- 
sider the effect of typhoid upon pregnancy, but in 
passing it is not without interest to observe that 
Freund and Levy * report a case of spontaneous 
abortion at the fifth month, at the beginning of defer- 
vescence, the mother, a multigravida, having suffered 
from a mild attack. They found the typhoid bacil- 
lus in the blood of the placenta and in the spleen 
and the heart of the fetus, thus proving the direct 
transmission of the bacillus from the mother to the 
fetus, which could not have taken place by any other 
channel than by the blood. The child died immedi- 
ately after birth, and the cultures were made twenty 
minutes later. No gross lesions were found in the 
fetus. Janizewski 2 reports a case of a woman, eight 
months pregnant, who, twelve days after her admis- 
sion into the hospital with typhoid fever, aborted of a 
fetus which lived five days. Bacteriological examina- 
tion of the fetus showed the typhoid bacilli in the 
spleen, intestines, mesenteric glands, kidneys, and 
luncrs. 

o 

Similar cases of ante-natal infection of the fetus 
are reported by Neuhass, Chantemesse and Widal, 
and a number of others, to which the references are 
given on page 32. 

Permterine Hematocele. — In addition to these 

1 Berlin, klin. Wochen., 1895, No. 25. 

2 Presse Med., March 24, 1894. 



288 SURGERY OF TYPHOID FEVER. 

cases, Guyot x has collected seven cases of peri- 
uterine hematocele of typhoid origin, which, with 
another by Trousseau 2 originating, as he believed, 
in a sanguineous cyst of the ovary in a girl of sixteen, 
are the only cases Dr. Westcott has found. Whether, 
as Guyot thinks, they arose from an intestinal per- 
foration is a question. 

In Guyot's four personal cases the trouble began, 
in three cases, respectively in the fourth, sixth, and 
seventh weeks of the fever, and in the fourth at the 
beginning of convalescence. This last case died, un- 
fortunately without autopsy ; two of the other three 
recovered without operation, but with persistence of 
the tumor. In the fatal case pus was discharged 
both from the rectum and the bladder. No autopsy 
was allowed. 

At the present day, undoubtedly, operation would 
be done in such cases, and as they all occurred 
practically in convalescence, the mortality would 
probably have been much less. The symptoms were 
in no wise different from the same disorder arising 
from other causes. No bacteriological examination 
was made, as it was before the discovery of the 
bacillus of Eberth. 

Lesions of the vagina are chiefly caused by ab- 
scesses (see Chap. VI) or gangrene (see Chap. Ill), 
and result in simple perforations, vesico-vaginal 
and recto-vaginal fistulae, destruction of more or less 
of the vagina, and sometimes entire closure of the 
vaginal outlet. These have already been considered. 

1 Etude sur l'hematocele periuterine survenant dans le cours on dans la con- 
valescence de la fievre typhoide, These de Paris, 1879. 

2 Clin. med. Hotel Dieu, 1865. 



CHAPTER XIX. 
SPECIFIC MIXED INFECTIONS. 

Tetanus. — Erysipelas. — Anthrax. — Malignant Edema. 

In addition to the ordinary pyogenic infections 
giving rise to complications in the joints, bones, 
larynx, parotid gland, etc., and producing various 
forms of septic lesions, there are a number of cases 
of other mixed infections with certain specific micro- 
organisms to each of which a few words will be 
appropriate. Some of these specific infections may 
find a port of entry through the intestinal lesions, 
but most of them probably gain an entrance through 
the bedsores, furuncles, suppurating parotid glands, 
and other similar avenues in the skin and the 
mucous membrane of the mouth. Some peculiar 
and characteristic avenues of infection in the cases 
of tetanus are considered under that heading. 
Among these infections the most frequent is ery- 
sipelas ; next to this is tetanus ; and there are one 
case of anthrax infection and two of malignant 
edema. Before the discovery of the typhoid bacillus 
and the bacteria of these various infections their 
occurrence was inexplicable, but now this is perfectly 
plain. They are all cases of mixed infection with 
other specific germs in addition to that of typhoid. 

Brysipelas. — The most important paper I have 
found in reference to erysipelas is Gerente's These 
19 289 



290 SURGERY OF TYPHOID FEVER. 

de Paris, 1883. 1 He collected up to that date 64 
cases of facial erysipelas in 3910 cases of typhoid 
fever, as is shown by the following table : 

Typhoid Facial 
Fever. Erysipelas. 

Chomel, 130 4 

Louis, 134 3 

Forget, 92 1 

Jenner, 65 2 

De Larroque, 105 4 

Zuelzer, 84 3 

Liebermeister, ....... 1420 10 

Zuccarini, 480 18 

Griesinger, 500 10 

Murchison, 900 9 

Total, 39 IQ 64 

The references to the several papers may be 
found in the original thesis. 

According to these figures, erysipelas is a compli- 
cation once in every 61 cases of typhoid. Erysip- 
elas, however, I believe is very frequently not 
mentioned, either because it is deemed an unimpor- 
tant complication or because it is infrequent. That 
it is an infrequent complication is shown, I think, 
by the fact that the other cases in our table number 
only 29. There are a large number of cases of 
erysipelatous infection alluded to in a general way, 
but these would not serve my purpose for analysis. 
Only the few cases stated above were found de- 
scribed in such detail as to be useful. 

The great majority do not arise in connection 
with the so-frequent bedsores, but more often, prob- 
ably, from the fissures of the lips and other solutions 

1 L'Erysipele de la Face dans le cours de la Fievre Typhoide. 



SPECIFIC MIXED INFECTIONS. 291 

of continuity about the head and face. This ac- 
counts for the much greater frequency of erysipelas 
of the face than of other parts of the body. In 
addition to this, the erysipelas not infrequently 
attacks the mucous membrane of the mouth and 
pharynx, and may travel down the trachea and 
result in either bronchitis or pneumonia, or may in- 
volve the vocal chords, producing great hoarseness 
and also dysphagia. Of this Jenner has given two 
excellent illustrations, 1 the first of which, however, 
occurred in a case of typhus. In the skin, espe- 
cially in such lax tissues as the eyelids, a local 
necrosis or gangrene may result. Meningitis does 
not seem to be a frequent sequence. The inflam- 
mation of the skin is sometimes stationary, or more 
commonly serpiginous or ambulant. Its duration 
may be fixed ordinarily at two weeks, but it varies 
very much. Two cases I have personally seen 
resulted in abscesses ; one, an abscess of the scalp 
and eyelid, the other, over the mastoid process. 

Case L VI. — A. C, age twenty-two, was admitted 
to St. Agnes' Hospital, April 14, 1891, on the fourth 
day of typhoid fever. She was under the care of 
Dr. H. A. Hare. On April 27th she developed 
facial erysipelas. By June 25th the erysipelas and 
typhoid had both subsided, but she was transferred 
to the suroical ward on account of an abscess over 

o 

the left mastoid. On the next day I opened the 
abscess and packed it with bichlorid gauze. She 
was discharged, cured, July 4, 1891. 

Case LVIL — J. W., age twenty-five, was admitted 
to St. Agnes' Hospital April 21, 1891, with begin- 

1 Med. Times (London), 1850, vol. xxi, p. 135 ; and Med. Times, n. s. , 
vol. i (o. s., vol. xxii), 1S50, p. 405. 



292 SURGERY OF TYPHOID FEVER. 

ning typhoid fever, and placed in the medical ward. 
May 10, 1 89 1, he developed facial erysipelas and 
the right eyelid threatened to slough. June 3, 1 89 1, 
on account of an abscess on the back of his head, 
he was transferred to the surgical ward, the ery- 
sipelas having subsided. June 4, [891, I opened 
the abscess. Another developed in the right eye- 
brow, and was opened June 8th. Both were healed 
by July 2, 1891, and he was discharged cured. 

Unfortunately, no bacteriological examination 
could be made in either case. 

Of the whole number, 82 were in the head and 
face, 1 of the foot and leg, 1 began in the arm, and 
1, reported by Berthand T (in 1848, be it observed), 
was said to be " erysipelas of the iliac and renal 
veins." The autopsy showed a plastic and sup- 
purative inflammation of these veins. Presumably 
this was a case of thrombosis. 

One case 2 is remarkable for its malignant course. 
It broke out on the thirteenth day in a woman of 
twenty-five, who was four and a half months preg- 
nant. Beginning in one arm, it spread over both 
arms, the chest, face, and head within twelve hours, 
when the patient died. 

Nearly all the patients were between twenty and 
thirty — 19 out of 28 cases in which the age is 
given. Five were below twenty (one each of twelve 
and eighteen and three of nineteen) and four were 
thirty-two, thirty-eight, forty, and forty-two years of 
age respectively. The two sexes were nearly 
equally attacked — 16 males, 14 females. It begins, 
usually, either in the third week, when the fever is 

1 Gaz. des Hop., v, 29. 2 Rosenberg, Columbus Med. Jour., 1890, 299. 



SPECIFIC MIXED INFECTIONS. 293 

at its height, or during convalescence, occasionally 

as late as the fifth to the eighth week. 

Its fatality is not to be wondered at. Twenty- 
seven cases died and 32 recovered of the 59 cases 
in which the result is stated. This gives a mortality 
of almost 46 per cent. The later cases since the 
introduction of antiseptics give even a worse result, 
for of 23 cases of the 29 collected in addition to 
those of Gerente, 11 died and 12 recovered, a mor- 
tality of almost 48 per cent. 

The only bacteriological examinations that have 
been made in these cases are by Rheiner, 1 and in 
his two cases the typhoid bacillus alone was found. 
Further examination will probably prove that the 
streptococcus is present, as a rule. 

The symptoms are the usual ones of erysipelas, 
but instead of beino- aggravated from the combina- 

o 00 

tion with the typhoid fever, as one would suppose, 
they all seem to be ameliorated. There is, as a 
rule, less redness, less pain, and less swelling than in 
other forms of erysipelas, nor does the temperature, 
as a rule, rise so high as we would expect. Delirium 
also is not very marked. The cause of the great 
fatality seems to be rather the general condition of 
the patient, especially his double infection. 

In the matter of treatment there is nothing which 
calls for special mention, except as to prophylaxis. 
The most scrupulous cleanliness, especially in any 
solutions of continuity, — such as fissures of the 
lips, nose, etc., bedsores, abscesses, furuncles, etc. 
Now that the great mortality from erysipelas is 
shown, a still more rigid antiseptic treatment, will, 

1 Loc. cit. 



294 SURGERY OF TYPHOID FEVER. 

in all probability, avert the danger by preventing 
the secondary infection. 

Tetanus. — In the Bibliography of my Toner 
Lecture I recorded six cases of tetanus, to which 
Dr. Westcott has added nine — 15 in all. 

The most interesting point in connection with 
these cases is the port of entrance of the infection. 
Thus, one case of the earlier series was believed 
to have arisen from a bedsore ; one had a wound 
on his finger; one 1 probably developed infection 
through a blister; two 2 were attributed to a possi- 
ble abrasion of hemorrhoids by a syringe (?); one 3 
followed eight days after plugging of the nares for 
uncontrollable hemorrhage ; one 4 followed the bite 
of a horse on the finger six weeks before ; and one 5 
occurred in a cavalryman who fell out of a window 
while delirious. In the earth where he fell the 
bacillus of tetanus was found. His occupation also 
is significant. 

Of the 15 cases, 13 (including all of those of the 
second series) followed typhoid and two typhus ; 
six were women, seven were men. Of the 15, ten 
died. Two women who recovered had menstrual 
irregularities, to which the alleged tetanus might 
have been due (?), and one man was said to have 
had a similar attack four years before. The remarks 
as to the treatment of erysipelas apply to that of 
tetanus as well. 

Anthrax. — That anthrax should complicate ty- 

1 Simoneau, Jour, de Med. de l'Ouest, 1882, 8. 

2 Fussell, Phila. Med. Times, Jan. 13, 1883, 263. 

3 Fowler, Buffalo Med. and Surg. Jour., 1880-81, xx, 155. 

4 Wolfinger, Ann. Stadtl. Allgem. Krankenh., Miinchen, 1878, i, 44. 

5 Belhomme, Arch, de Med. et Pharm. Milit, 1890, No. 6, 464. 



SPECIFIC MIXED INFECTIONS. 295 

phoid fever is quite unexpected. Only one case is 
recorded, that of a soldier 1 who died after having 
had intestinal hemorrhages and with enlarged 
spleen. In the stools during life, and in the blood, 
the intestines, the liver, and the spleen after death, 
were found the bacilli of anthrax. The stomach 
and intestines showed a number of tumors ; Peyer's 
patches and the solitary follicles were eroded and 
the mesenteric glands enlarged ; the spleen was 
five times the normal size. In the cecum and ileum 
were found the bacilli of typhoid. The anthrax 
infection was traced to some milk his sister had 
brought him from a cow which had evidently suf- 
fered from anthrax. 

Malignant Edema. — Brieger and Ehrlich 2 re- 
port two cases in which malignant edema compli- 
cated typhoid. They attribute it to the use of the 
tincture of musk for collapse. 

The first was a woman of twenty-six. On the 
thirteenth day the musk was injected in the right 
thigh by a hypodermatic syringe. In two days there 
was severe pain and rapidly spreading gangrene, 
and she died the next day. The other was a woman 
of thirty-two in whom the same tincture was injected 
in the thigh with a similar result. In both cases the 
bacillus of malignant edema was found. 

1 Karlinski, Berlin, klin. Wochen. , 1888, No. 43, 866. 

2 Berlin, klin. Wochen., 1882, 661. 



CHAPTER XX. 

OCULAR COMPLICATIONS OF TYPHOID FEVER. 
/ 

BY GEORGE E. de SCHWEINITZ, A.M., M.D. 

History. — Disregarding for the moment the spe- 
cific diagnosis, — typhoid fever, — a word in regard 
to post-febrile ocular complications in general may 
be in place. 

In 1826 Dr. A. Jacob 1 described iritis as a se- 
quence of relapsing fever, as this was first estab- 
lished by Hewson in his work on Venereal Oph- 
thalmia. About the same time William Wallace 2 
contended that this inflammation could be cured by 
"bark or quinin." In 1846 Dr. Jacob 3 returned 
to this subject in a communication entitled " On 
Inflammation of the Eye following Fever." His 
paper refers especially to a form of fever epidemic in 
Glasgow in 1843, and similar to that which prevailed 
in Dublin in 1826. This fever was described by 
Mackenzie, 4 and the ocular complications designated 
Post-febrile Ophthalmitis. They manifested them- 
selves in a form of irido-choroiditis. Of 135 cases 
analyzed by A. Anderson, of Glasgow, 5 10 began 
during the fever or its relapse ; 34 began at once on 
convalescence ; 29 within a fortnight of convales- 

1 Trans. Coll. of Phys. Ireland, Dublin, 1828, v, 46S-478. 

2 Meclico-Chir. Trans., London, 1828, xiv, 286-322. 

3 Dublin Med. Press, 1846, xv, 17-21. 

4 London Med. Gazette, n.s.,vi, 1843-44, 225-236. 

5 Month. Jour. Med. Sc., London and Edinb.,' 1845, v > 729—773. 

296 



OCULAR COMPLICATIONS. 297 

cence ; 31 within the following month ; and 31 within 
five or six months. 

Similar severe inflammation of the eye following- 
typhus fever, as it appeared in New York in 1 CS47— 
4c8, has been reported by A. Dubois, 1 and again by 
Wilkes and Dubois. 2 

In 1870 post-febrile ophthalmitis received consid- 
eration from M. Charteris, 3 who investigated the 
cases of relapsing fever which occurred in Glasgow 
in 1870, and which, both from the ocular and gen- 
eral standpoint, were identical with those reported in 
the communications already referred to. The oph- 
thalmic disease, as already stated, was an irido-chor- 
oiditis, which, if neglected, passed into ophthalmitis. 

In 1878 Dr. N. Larionow 4 examined y6j typhus 
patients and typhus convalescents in order to ascer- 
tain the influence of the typhoid process upon the 
oro-ans of vision. Anion or the ocular lesions which 

o o 

he described were conjunctivitis, iritis, keratitis, vit- 
reous opacities, retinitis, neuritis, and " amblyopia 
and amaurosis." 

From the preceding paragraphs it is evident that 
post-febrile ocular disease has been known for a 
long period of time as a complication of typhus 
and recurrent fevers, but less commonly of typhoid 
fever, although Larionow especially mentions typhus 
abdominalis. 

Classification of the Ocular Complications and 
Sequela? of Typhoid Fever. — In an article on the 

1 Trans. Amer. Med. Assoc, Phila., 184S, i, 375-3S6. 

2 Annalist, N. Y., 1848, ii, 331-333. 

3 Glasgow Med. Jour., 1870-71, 4th series, iii, 347-354. 

4 Klin. Monatsbl. f. Augenbeilk., Cassel, 187S, xvi, 487-497. 



298 SURGERY OF TYPHOID FEVER. 

alterations of vision in typhoid fever, Galezowski T 
submits the following classification: (1) Necrosis of 
the cornea ; (2) thrombosis of the ophthalmic and 
orbital veins ; (3) embolism of the central artery of 
the retina ; (4) optic neuritis, with atrophy of the 
disc ; (5) defects of accommodation. 

An examination of the literature justifies a more 
elaborate classification, namely: (1) Affections of 
the conjunctiva and cornea ; (2) affections of the 
uveal tract — iris, ciliary body, choroid— and of the 
vitreous humor; (3) affections of the crystalline 
lens ; (4) affections of the optic nerve, retina, and 
retinal vessels ; (5) affections of the orbit and orbital 
circulation ; (6) affections of the extra- and intra- 
ocular muscles. Although not strictly ocular affec- 
tions, to this list may be added affections of the cav- 
ernous sinus from extension of a diseased orbital 
process, affections of the sympathetic, and sloughing 
of the lids in association with noma of the face. 

Relative Frequency of the Ocular Complications 
of Typhoid Fever. — If feebleness of accommodation 
as part of a general post-febrile weakness is excepted, 
affections of the conjunctiva and cornea are the most 
frequent ocular complications of typhoid fever. The 
cases of conjunctivitis (catarrhal and phlyctenular) 
far outnumber those of ulcerative keratitis. Sup- 
purative keratitis, while fortunately not a common 
complication, 2 occurs with sufficient frequency to 
accord it more attention than it has thus far received. 

1 L'Union Med., 1877, 3^ series, xxiii, 937-941. 

2 August Hoelscher (Miinch. med. Wochen., 1891, xxxviii, 43 ; 62) 
has seen it twice in 2000 fatal cases ; Osier does not even mention its 
occurrence. 



OCULAR COMPLICATIONS. 299 

The remaining- ocular lesions occur probably in the 
following order of frequency: Retinal hemorrhages, 
diseases of the uvea and vitreous, paralyses of the 
ocular muscles, neuritis and neuro-retinitis, and, 
finally, orbital affections. It is not unlikely that if 
ophthalmoscopic examinations were systematically 
undertaken in typhoid fever, the relative frequency 
of retinal hemorrhages would rise, and, indeed, the 
relative frequency of fundus lesions in general, 
because they attract attention only when they are so 
situated that they involve the macular region and 
occasion disturbances of visual acuity of which the 
patient complains. 

I. Affections of the Conjunctiva and Cor- 
nea. — Ordinary conjunctivitis of the catarrhal type, 
differing" in no sense from those varieties which are 
common to a number of febrile states, is frequent in 
typhoid fever. According to Knies, 1 during conva- 
lescence, and still more at a later period, phlyc- 
tenular affections, both of the cornea and of the 
conjunctiva, have been observed. 

Of more serious import are the various types 
of ulcerative keratitis and sloughing of the cornea, 
occurring usually during the convalescent period, or, 
at all events, after the disease has existed for a suffi- 
cient length of time to have seriously depressed 
nutrition. Ulcer of the cornea may be preceded by 
the development of phlyctenules, or it may appear 
without such antecedents and rapidly pass into the 
sloughing type of keratitis with all its consequences. 

1 Die Beziehungen des Sehorgans und seiner Erkrankungen zu den 
iibrigen Krankheiten des Korpers und seiner Organe, Wiesbaden, 1893, 
P- 395- 



300 SURGERY OF TYPHOID FEVER. 

Cases of this character are reported by Knies, 1 
Hoelscher, 2 Galezowski, 3 Adolph Alt, 4 and a number 
of other observers. The following case histories 
illustrating types of this affection are appended : 

Case L VIII. — Hypopyon Keratitis with Iritis 
Occurring in the Fourth Week of Typhoid Fever. — 
Notes furnished by Dr. C. A. Veasey, of Philadelphia, 
as follows : A married woman in the fourth week of 
typhoid fever, complicated with pneumonia, de- 
veloped a deep ulcer at the upper and inner quad- 
rant of the cornea, together with iritis and hypopyon. 
Under atropin, boric acid lotions, irrigations with 
formaldehyd, and, finally, the application of the 
actual cautery to the ulcerated surface, healing took 
place with the preservation of vision of J, the 
cornea being clear except for a scar marking the 
position of the ulcer. There was one relapse of 
this ulcer two and one-half weeks after the original 
treatment had been begun, which rapidly yielded to 
the same measures. 

Case LIX. — Ulceration of the Cornea Followed 
by Rapid Sloughing of this Structure, Occurring at 
Vie End of the Fourth Week of Violent Typhoid 
Fever. — Notes furnished by Dr. W. S. McClanahan, 
of Woodhull, 111., as follows : A man, age twenty- 
three, was first seen on October 9th, with typhoid 
fever, his temperature at that time being 103.5 . 
The symptoms were severe from the very begin- 
ning, and in the third week the patient suffered 
from violent intestinal hemorrhages. Diarrhea, 
rapid emaciation, and delirium were prominent 
symptoms. 

Ulceration of the right cornea was first noticed 
toward the end of the fourth week, beginning in a 
small point of infiltration near its lower margin. In 



1 Loc. cit. 2 Loc. cit. 3 Loc. cit. 

4 Med. Fortnightly, 3, 4, 1893, p. 47. 



OCULAR COMPLICATIONS. 301 

five days the entire cornea had passed into a state 
of ulceration, and the anterior chamber had filled 
with pus. Spontaneous rupture of the cornea and 
prolapse of the iris followed. Surgical interference 
was forbidden. When last seen by the reporter 
the inflammatory conditions were subsiding, although 
vision was practically nil. 

The question of medico-legal responsibility in 
such destructive lesions of the eye has recently been 
brought to the attention of the courts, and, accord- 
ing to the Journal of the American Medical Associa- 
tion, 1 has been decided as follows : 

"No Duty to Provide Specialist. — In the case of 
Jones vs. Vroom, decided by the Court of Appeals of 
Colorado, May 11, 1896, suit was brought against a 
firm of physicians to recover damages for the loss 
of an eye [from an ocular complication the result of 
her typhoid fever], alleged to have been caused by 
the negligent and unskilful treatment of the de- 
fendants. They had been employed to treat the 
plaintiff for typhoid fever. There was no evidence, 
and in fact no complaint, that they did not bestow 
upon her all the attention and skill which the nature 
of the disease and her condition required. Indeed, 
she stated herself that she was cured of the fever 
as a result of their treatment. The only charge in 
the complaint which was proven was that one of 
the defendants failed to send her an oculist after 
he had promised to do so. The Court holds that, 
under the circumstances, a nonsuit was properly 
granted. It says that the defendants were em- 
ployed to treat the plaintiff for fever, and their 
employment imposed no duty upon them to provide 
her with a specialist for her eye. The Court took 
into account, furthermore, that she seemed to have 

1 July 18, 1896, p. 169. 



302 SURGERY OF TYPHOID FEVER. 

had no difficulty in procuring one when she set 
about it, and says that presumably he could have 
been gotten just as readily at first." 

According to Charles Stedman Bull, 1 who quotes 
Knies, in the somnolent or comatose stage of severe 
and fatal cases of typhoid fever, a rare complication 
is a true xerophthalmia, or xerosis cornece. The 
same affection has been observed in cholera, diar- 
rhea, and meningitis. 

The treatment of the conjunctivitis of typhoid 
fever does not differ from that which is applicable 
to a similar conjunctivitis occurring under other cir- 
cumstances — namely : a mild antiseptic lotion — for 
example, boric acid, or formalin, i : 6000. Severe 
corneal complications demand those measures which 
are suited to sloughing ulcers of other origins — 
namely : irrigation of the conjunctival cul-de-sac with 
a solution of formalin, 1 : 2000, or saturated boric 
acid, or bichlorid of mercury, 1 : 8000, atropin drops 
to control complicating iritis, and, if the ulcer ex- 
tends, touching its surface, after the sloughing mate- 
rial has been curetted away, with a solution of ni- 
trate of silver, ten grains to the ounce, or tincture 
of iodin, or, in severe cases, the actual cautery. If 
hypopyon develops, it should be evacuated by a 
paracentesis of the cornea. Powdered iodoform 
may be dusted upon the corneal surface with advan- 
tage. 

The prognosis of suppurative keratitis is very bad, 
especially when it appears in aggravated cases of 
fever, or when the general treatment of the typhoid 

1 Med. Record, New York, 1897, vol. li, p. 577. 



OCULAR COMPLICATIONS. 303 

fever has been neglected ; as, for example, in the 

cases reported by Adolph Alt, which occurred in 
very poor patients who had been unable to obtain 
proper attention. Under the best of circumstances 
so happy a result as that achieved by Dr. Veasey 
may be accomplished ; under other circumstances, 
even with the most careful treatment, extensive 
sloughing of the cornea may result as in the case 
recorded by Dr. McClanahan. 

II. Affections of the Uveal Tract — Iris, Cil- 
iary Body, Choroid — and the Vitreous Humor. 
— As may have been inferred from the earlier por- 
tion of this chapter, affections of the uveal tract are 
much more frequent in relapsing and typhus fever 
than in pure typhoid fever. None the less, iritis, 
cyclitis, and choroiditis, either in the serous or the 
plastic form, and associated with opacities of the 
vitreous, are occasionally encountered during typhoid 
fever, especially during convalescence. F. Sorel, 1 in 
an analysis of 871 cases of typhoid fever observed 
during a period of ten years, notes only one case of 
iritis during the period of convalescence. In spite 
of the apparent infrequency of inflammation of the 
iris, or of the uveal tract generally, I am persuaded 
that more minute examination of the visual organs 
during typhoid fever would reveal a greater preva- 
lence of affections of this tract than might be inferred 
from such statistical information as has just been 
quoted. Alt has seen plastic choroiditis with opacity 
of the vitreous after a severe attack of typhoid fever, 
and I have observed post-typhoidal choroiditis and 
secondary atrophy of the disc. 

1 Bull, et Mem. de la Soc. Med. des Hop., 1889, vi, 3, s., 224-246. 



304 SURGERY OF TYPHOID FEVER. 

The floating opacities which occur in the vitreous, 
according to Bull, are of the punctate or stringy 
variety, but are not fixed and membranous. 

There is some evidence to show that spontaneous 
inflammation of the vitreous, which may manifest itself 
simply as an opacity, or even go on to suppuration, 
may be due to the exhaustion and debility conse- 
quent upon a low fever like typhoid, and, as Howard 
F. Hansell has pointed out, if during the earlier 
stages of the fever the discovery is made that fine 
flakes of opacity are beginning to appear in the vit- 
reous, it is possible that a vigorous supporting treat- 
ment may save the eye from destruction. Although 
Bull states that these uveal tract inflammations are 
serous or plastic in type, but never purulent, it would 
seem that this rule is subject to exceptions, and that 
a purulent choroiditis similar to that which is seen 
in pyemia, puerperal sepsis, or endocarditis, may 
occasionally complicate typhoid fever. A case in 
point is the following : 

Case LX. — Panophthalmitis Occurring at the Be- 
ginning of the Third Week of Typhoid Fever and 
Resulting in Phthisis Bulbi. Notes furnished by Dr. 
C. W. Hall, of Kewanee, 111. A woman, age thirty, 
was taken ill with typhoid fever on October 29, 1895. 
During the first week headache was severe, the tem- 
perature ranged between 101 and 104 F., and 
there were marked tympanites, abdominal tender- 
ness, and moderate diarrhea. On the sixteenth day 
throbbing pain began in the left eye. quickly followed 
by loss of vision. In a few days the symptoms of 
panophthalmitis were marked, especially edema of the 
lids and chemosis of the conjunctiva, and, in fact, 
swelling of all the tissues surrounding the eye. The 



OCULAR COMPLICATIONS. 305 

eye gradually grew worse and sloughing of the ocular 
tissues supervened, followed by atrophy of the eye- 
ball, which gradually shrank to the size of a large 
hazelnut. 

In this case, as there is no report of external 
lesion of the cornea, the disease beginning with pain 
and loss of sight, we may assume a purulent cho- 
roiditis caused by embolism from a microbic area. 

The treatment of cases of uveal tract inflamma- 
tion must be governed by the type of the disease. 
In iritis the mydriatics are indicated, and the same 
remedies would be advisable in inflammations of the 
deeper structures. Success would depend, as has 
already been pointed out, upon being able to sup- 
port the nutrition of the patient. If purulent cho- 
roiditis should arise, followed by panophthalmitis, 
incision of the eyeball and evisceration of the puru- 
lent contents would be required. 

III. Affections of the Crystalline Lens. — As 
the result of inflammation of the uveal tract, the nu- 
trition of the lens is interfered with and cataract may 
result. Without such antecedent inflammation, 
opacity of the crystalline lens has been attributed to 
the nutritional disturbances occurring during typhoid 
fever. For example, Trelat l has described double, 
semi-soft cataracts in a young girl, which began to 
develop during convalescence from typhoid fever-, 
and Fontan 2 reports three cases of post-typhoid 
cataract (cataracta punctata) which he believes were 
the result of mechanical obstruction of the circula- 
tion. In two of these cases, one a twenty-eight-year- 

1 Gaz. des. Hop., 1879, p. 417. 

2 Rec. d'Ophtal., 1887, 3> s > i x > 195-200. 



306 SURGERY OF TYPHOID FEVER. 

old man, and die other a forty-two-year-old woman, 
the cataract progressed to maturity and required 
extraction. Unfortunately, there is no evidence to 
show that Fontan was aware of the condition of the 
transparent media before the typhoid attack. 
Romiee x has analyzed 44 cases of cataracta punctata, 
and attributes the pathogenic cause to typhoid fever 
in 17 of them. He seeks to explain the lenticular 
opacity by an increase in the density of the serum 
and changes in the relation of the lens to the aqueous 
humor. It is most likely that all cases of post-febrile 
cataract are originally due to disturbances of moder- 
ate or greater grade in the uveal tract, necessarily 
followed by changes in the nutrition of the lens. An 
interesting surgical fact in connection with these cases 
is that they seem to do as well after extraction, as 
those cataracts w r hich have not developed through 
such a complication. 

IV. Affections of the Optic Nerve, Retina, 
and Retinal Blood-vessels. — Double optic neuritis 
may occur and end in atrophy of the nerve or in 
recovery; as, for example, in cases recorded by Noth- 
nagel, Hutchinson, Sr., Clifford Allbutt, and in our 
own country by Augustus P. Clarke 2 and J. A. 
White. 3 The last observer not only gives his own 
experience in this particular, but has gathered the 
observations of a number of American ophthalmic 
surgeons who have from time to time noted cases of 
neuritis and optic nerve atrophy attributed to typhoid 
fever. 

1 Rec. d'Ophtal., 1879, 3> s -> h 586-593. 

2 Jour. Amer. Med. Assoc, 1891, xvi, 473-476. 

3 Trans. Ophth. Section Amer. Med. Assoc., Chicago, 1893, 215-223. 



OCULAR COMPLICATIONS. 307 

Some doubt in regard to the reality of this typhoid 
neuritis has been expressed, especially by Leber and 
Stellwag von Carion, who have suggested that the 
cases in which it occurred may have been meningitis 
instead of typhoid fever. Commenting on this, how- 
ever, Gowers points out that neuritis does occasion- 
ally follow other acute specific diseases. Neuritis 
of other nerves than the optic has been observed in 
typhoid. 

Robert P. Oglesby ' has never met with a case of 
optic nerve trouble after typhoid fever unless there 
have been symptoms of meningitis. In his opinion, 
the condition is not one of actual neuritis, but of so- 
called subacute neuritis. According to this author, 
cases of typhoid fever amblyopia are more frequent 
among women than among men, and especially 
among child-bearing women. A history of cerebral 
neuralgia and meningitis can always be obtained. 
Gowers, on the other hand, referring to the fact 
that cases of typhoid fever accompanied by hyper- 
emia of the discs have been supposed to be cases 
complicated by meningitis, points out that menin- 
gitis, except as secondary to suppuration in the ear, 
is exceedingly rare in this disease, and that it is not 
warranted to infer meningitis because there is ex- 
treme delirium or coma. Meningitis not arising 
from ear disease, but from direct microbic infection, 
however, is recorded by Keen in Chapter VIII. 

Braine-Hartnell 2 has reported a case which proves 
that bilateral optic neuritis may complicate typhoid 

1 Brain, London, 1882, v, 197-203. 

2 British Medical Journal, May 29, 1897 ; also Medical Record, New 
Vork, vol. lii. p. 349. 



308 SURGERY OF TYPHOID FEVER. 

fever when there is no meningitis. His patient was 
a boy, eleven years old, who suffered from fever, 
diarrhea, photophobia, cerebral irritation, retraction 
of the abdomen, dry tongue, and sordes on the 
teeth. There were no spots, however, and the spleen 
was not enlarged. There was never any strabismus, 
nor were convulsions present. Two days before 
death there was slight inequality of the pupils, and 
well-marked bilateral optic neuritis developed. 
Neither aural nor nasal discharge was detected. 
The post-mortem examination revealed distinct in- 
flammation of Peyer's patches, with decided enlarge- 
ment of the mesenteric glands and solitary follicles. 
Nothing was found in the brain to explain the optic 
neuritis. 

In my examinations of typhoid fever cases in the 
Philadelphia Hospital, while I have seen hyperemia 
of the discs, I have never observed actual neuritis in 
cases uncomplicated with meningitis ; in fact, in one 
case in which the diagnosis was somewhat uncertain, 
and which came to autopsy, the lesions of a dissemi- 
nated tubercular meningitis were present, but no 
signs of the typhoid process. I have therefore come 
to regard optic neuritis as in a certain sense a valu- 
able differential diagnostic point in cases of low 
fever of uncertain origin. 

Optic nerve atrophy, either partial or complete, may 
follow the neuritis, or, either single or double, may 
be present without preceding inflammation. These 
cases are usually noticed first in the convalescent 
period and come under more exact examination as 
post-typhoidal phenomena. A matter of some im- 
portance in determining the etiology of cases of 



OCULAR ( OMPLIi A 7/ONS. 309 

post- febrile atrophy is to ascertain what treatment 
the patient has undergone, because it is well recog- 
nized that the excessive use of quinin during the 
fever may occasion amblyopia and even partial 
optic nerve atrophy. Intestinal hemorrhage may 
also be the exciting cause of permanent blindness 
from atrophy of the optic nerve, precisely as this 
occurs after hematemesis. Amblyopia has also fol- 
lowed severe epistaxis (Ebert, quoted by Knies) and 
menstrual hemorrhage during typhoid fever, as re- 
ported by C. Williams. 1 

Instead of intraocular optic neuritis, temporary 
or permanent impairment of vision may be due to 
retrobulbar neuritis, which may perfectly recover or 
eventuate in optic nerve atrophy. These cases 
have been referred to by Knies, and, as has been 
suggested by Bull, are difficult to study because the 
patient is usually too ill to permit perimetric exami- 
nation, which, no doubt, would reveal a central sco- 
toma. Occasionally the blindness may be due to a 
retrobulbar neuritis, caused, probably, by a hemor- 
rhage into the optic nerve, as in a case reported by 
Leber and Deutschmann, which is quoted by Knies. 

Amblyopia without ophthalmoscopic changes, simi- 
lar to the blindness occurring after or during- scarlet 
fever, has been recorded, for example, by Ebert 2 and 
by Nothnagel, 3 and presents a favorable prognosis, 
the affection, according to Gowers, usually passing 
away in the course of several weeks. 

Leber has described anesthesia of the retina, and 

1 Archives of Ophthalmology, New York, 1884, xiii, 397-399. 

2 Berl. klin. Wochen., 1868. 

3 Deutsch. Archiv f. klin. Med., 1872, ix, 470. 



310 SURGERY OF TYPHOID FEVER. 

Hersing an annular defect in the visual field. J. 
Stewart * has observed, in a case of typhoid fever 
in a man aged thirty-two, setting in with men- 
ingitic-like symptoms, an island-shaped scotoma. 
The symptoms were attributed to .blood intoxication. 

Neuro=retinitis with macular hemorrhages has been 
described by von Petershausen, 2 and Munier 3 has 
reported double blindness from neuro-retinitis. In 
his case there was probably a complicating meningo- 
encephalitis. 

According to Charles Stedman Bull, retinal hemor- 
rhages are by no means uncommon in the height of 
typhoid fever. They vary in size, shape, and ap- 
pearance, according to the portion of the retina in 
which the extravasation takes place, and are said 
usually to appear about the third week of the dis- 
ease. They may burst through the limiting mem- 
brane and involve the vitreous. Sometimes they 
manifest themselves in association with intestinal 
hemorrhage. 

The exact cause of retinal hemorrhage in this dis- 
ease has not been determined, but it probably de- 
pends, as Bull has suggested, either upon a weak- 
ened condition of the blood-vessel walls, or a per- 
verted quality of the blood, or both combined. 
Sometimes, no doubt, there is rupture of the vessel 
wall itself and sometimes a diapedesis. A micro- 
bic invasion of the vascular walls has been suggested 
by Dr. Keen (pp. 60 and 172) as a possible explana- 
tion of these and kindred hemorrhages. I am con- 

1 Montreal Med. Jour., 1894-95, xxiii, 752-758. 

2 Detroit Rev. Med. and Phar., 1873, v "»» 533-54 1 - 

3 These de Paris, 1874. 



OCULAR COMPLICATIONS, 311 

fident that retinal hemorrhages are much more com- 
mon in typhoid fever than is generally supposed. 
The subject appears, in large measure, to have 
escaped the attention of clinicians. 

Finally, a few cases of embolism of the central artery 
of the retina have been observed during the conva- 
lescence from typhoid fever ; for example, by Gale- 
zowski ' and Snell. 2 

V. Affections of the Orbit and Orbital Cir- 
culation. — Galezowski refers to the fact that Bur- 
geois and Trousseau, among other complications, 
have reported thrombosis of the orbital veins, and 
Caron du Villards, phlegmon of the orbit. Orbital 
cellulitis as a complication of typhus is well known. 
It is possible that some of the cases may have been 
due to typhoid fever. Indeed, Swanzy and one or 
two other authors mention typhoid fever as a cause 
of inflammation of the orbital tissue, but o-ive no 
details. 

Panas 3 details the following remarkable case : A 
patient, seven years of age, who five years previ- 
ously had been under treatment for an angioma of 
the orbit, developed, during the course of typhoid 
fever, in the third week, phlegmonous inflammation 
of the orbit and panophthalmitis. When the bulbus 
was enucleated an angioma was found, the center of 
which had undergone suppuration. In the midst of 
the suppurating tissue bacteriological examination 
developed the presence of the bacillus of Eberth. 
Panas points out that this process must be explained 
on the theory of endo-infection, the thrombotic con- 

1 Loc. cit. 2 Ophthalmic Review, i, 403. 

8 Congres Francais de Chirurgie, 5th session, Paris, 1891, 63-69. 



312 SURGERY OF TYPHOID FEVER. 

clitions in the orbit presenting a particularly favorable 
field for the development of suppuration under the 
influence of the micro-organisms. 

A most interesting case of spontaneous orbital and 
intraocular hemorrhage occurring in the course of ty- 
phoid fever has been reported by C. A. Finlay. 1 It 
occurred in a boy, ten years of age, in the third week 
of typhoid fever, and was associated with the appear- 
ance of ecchymotic spots, not only in the conjunctiva, 
but all over the body and limbs. The corneae of 
both eyes sloughed. The patient recovered. Dr. 
Finlay has collected 26 cases of spontaneous orbital 
hemorrhage, but this is the only one which occurred 
during the course of typhoid fever. Finlay suggests 
that in his case there may have been some degenera- 
tive change in the walls of the blood vessels in con- 
nection with the general lowering of the nutrition, or 
else the condition should be considered as a compli- 
cating purpura. 

VI. Affections of the Intra- and Extra-ocular 
Muscles. — As has already been stated, during the 
period of convalescence dilatation of the pupil and 
paresis of accommodation is not an uncommon affec- 
tion. Segal 2 describes mydriasis in typhoid fever with 
normal accommodation and normal vision, and con- 
siders the dilatation due to an irritation of the sym- 
pathetic. 

Paralyses of the extraocular muscles during the 
height of typhoid fever, unless there is some grave 
intracranial complication, are exceedingly rare. 
Nothnagel has reported double ptosis and right 

1 Archives of Ophthal., New York, 1897, xxvi, 42-47. 

2 Archiv f. Augenheilk., Wiesbaden, 1889, xix, 386. 



OCULAR COMPLICATIONS. 313 

abducens paralysis at the beginning of the third 

week. 

In the period of convalescence the)' have been 
observed more frequently, and, according to Knies, 
may perhaps be attributed to a chronic nephritis, 
which in his belief is a frequent sequel of typhoid 
fever. According to this author, these paralyses 
recover quickly and also relapse quickly, and are 
nuclear in character. 

Finally, there may be muscular paralyses occurring 
at long periods after typhoid fever ; for example, a 
case of left trochlear paralysis reported by Rune- 
berg, which appeared one and one-half years after 
fever. The etiological relationship of the typhoid 
state to these palsies is very questionable. If there 
should be a complicating meningitis at the base of 
the brain, then, naturally, orbital muscle palsy might 
be expected, exactly as we find it in ordinary menin- 
gitis ; and, indeed, cases of this kind are not infre- 
quent. For example, Samuel West l observed during 
a mild attack of typhoid fever in a child, aged ten, 
retraction of the head and strabismus, which disap- 
peared within a few days, the case resulting in 
recovery. 

A complicating meningitis of the cortex, or at the 
base of the brain, might produce hemianopsia, which, 
according to Knies, is a very rare phenomenon. 

1 St. Barth. Hosp. Rep., 1886, vol. xxii, p. 224. 



CHAPTER XXL 
CONCLUSIONS. 

If now, by way of review r , we cast our eyes back 
over the general results of all the complications and 
sequels we have studied, we may arrive at some 
useful and. important conclusions. 

i. Typhoid, probably from its usually longer 
duration, is by far the more prolific source of such 
surgical troubles, except parotitis, especially when 
we consider that many cases tabulated as typhus 
are really typhoid. Of 1699 cases, typhoid was the 
preceding fever in 1 1 39, typhus in 494, and other 
forms of continued fever in 66. Of the 494 after 
typhus fever, 352 were cases of parotitis. In the 
paragraphs which follow I have entirely omitted these, 
as they would so warp the figures as to give false 
results. The statistics are therefore based nearly 
entirely upon the typhoid cases. The former tables 
not having been preserved, the typhoid and typhus 
cases in each lesion could not be discriminated ; 
but besides the cases of parotitis there were only 
1 19 in all. 

2. The surgical troubles to be apprehended in 
typhus, apart from parotitis (352 cases), are mainly 
restricted to gangrene and laryngeal stenosis, 103 
out of the 1 19 cases after typhus being due to these 
two classes of disease, while typhoid bears in its 
train any and all of the forms of disease described. 

314 



CONCLUSIONS. 315 

3. When the in fee lion is a mixed infection of the 
typhoid bacillus and other bacteria, the result is a 
complication rather than a sequel, and the course 
of the disease is apt to be early in its onset, acute, 
and of a febrile character. When the infection is 
by the typhoid bacillus alone, the result is a sequel 
lather than a complication, and the course of the 
disease is apt to be late in its onset, chronic, and 
afebrile. In the pure typhoid infections the disease 
is often local rather than general, and the patient's 
general health suffers but little. 

4. The cause of nearly all these surgical results 
(using this word to include both the complications 
and the sequels) of typhoid fever is the typhoid 
bacillus, and not, as I thought twenty years ago, the 
presence of a clot or of mechanical conditions. True, 
these mechanical conditions do influence the site of 
the lesions in many cases, as also does the existence 
of a clot, but the etiological factor of most impor- 
tance is the bacillus itself. The bacilli have not so 
far been found generally in the joints, in parotitis, otitis 
media, or the laryngeal lesions, and often not in gan- 
grene, abscesses, and hematomata; but their almost 
universal presence in the lesions of the bones, men- 
ingitis, abscesses, the gall bladder, and the spleen, 
would lead us to suspect their influence in the other 
cases, at least at some period of the disease. To 
many of the regions and organs of the body in which 
they are not usually found the pyogenic bacteria 
find a ready access, and undoubtedly exert a potent 
influence. But most of the surgical results can be 
attributed directly to the bacilli of the fever itself, 



316 SURGERY OF TYPHOID FEVER. 

aided by other bacteria and by unfavorable mechan- 
ical conditions. 

5. The clinical course of the surgical results of 
typhoid is worthy of a word. It is often peculiar in 
that the same complication or sequel affects multiple 
regions of the body — e.g. y a number of different 
bones — either simultaneously or successively; or, 
again, that two or more complications may attack 
the same patient — e.g., gangrene and an osseous 
lesion, or a laryngeal complication, and abscesses 
in different regions of the body. 

6. The period of development is not the initial 
period of the fever, but, first, from its height to its 
close — that is, the complications, especially gangrene 
and stenosis of the larynx ; and, secondly and most 
frequently, during convalescence — that is, the se- 
quels. Of 622 cases, only 12 arose in the first 
week, 113 in the second, and 78 in the third, a total 
of 203. If we may assume that convalescence, on 
the average, begins at the end of the third week, 
then 419 occurred during or after convalescence. 
Many of them occur months, and even years, after 
the fever. This is especially true of the lesions in 
the bones. That the typhoid bacilli may cause such 
late manifestations of disease has naturally been 
doubted. But the array of proof, bacteriological as 
well as clinical, in the preceding chapters would 
seem to be complete and to set at rest any linger- 
ing doubt. 

The pure typhoid infections are, as a rule, later in 
their onset; the mixed infections occur much earlier. 

7. The lower half of the body is the especial seat 
of such surgical troubles. With the exception, of 



CONCLUSIONS. 317 

course, of the cerebral, laryngeal, aural, thyroid, and 
thoracic cases and parotitis, and the cases of biliary 
and intestinal perforations, of 942 cases of general 
disorders, such as gangrene, osseous lesions, etc., 
51 5 occurred in the pelvic region and legs, as against 
427 in all other parts of the body. Moreover, the 
diseases attacking the upper half of the body are 
limited almost entirely to local gangrenes and osteo- 
myelitis, caries, and necrosis, and they are usually 
far less severe in type and more limited in extent 
than those in the lower half. Here whole limbs are 
blighted by gangrene ; here occur most of the dis- 
locations, the hematomata, the fistulae ; here the 
severest necroses and largest abscesses ; and were 
we to add the long catalogue of bedsores and 
phlegmasia^, the preponderance of the lower half 
of the body in importance would be still further 
increased. 

8. The age is about the usual age of greatest fre- 
quence of these fevers. 1 From fifteen to twenty- 
five years is by far the most frequent decade, count- 

1 Liebermeister gives the ages in typhoid as follows : 

Fifteen to thirty, I0 10 

Thirty to seventy-one, 394 

Total, 1,704 

None under fifteen were admitted. 
In typhus : 

Fifteen to thirty, 39 per cent. 

Murchison gives in typhoid : 

Fifteen to twenty-five, 2, 75 2 

All other ages, 3,159 

Total, 5>9H 

And in typhus : 

Fifteen to twenty-five, 5,332 

All other ages, 12,806 

Total, 18,138 



3 I 8 SURGER Y OF TYPHOID FEVER. 

ing 361 cases against 353 at all other periods of 
life. One singular exception is to be made — viz., 
the articular troubles, and especially dislocation of 
the hip, 32 out of 35 cases being under twenty years 
of age, of which 21 were in children under fifteen — 
in striking analogy to the frequency of coxalgia in 
children. 

9. Sex is an unexpected and important factor in 
the predisposition to febrile surgical troubles. Of 
745 cases in which the sex is named, 488 are males 
and 257 are females, or nearly two to one. What 
is the normal proportion of the sexes in fever it 
is difficult to determine. In nearly 6000 cases of 
typhoid, Murchison gives the proportions as pre- 
cisely equal, and in over 18,000 cases of typhus the 
females were in a decided majority (8871 to 9267). 
Estlander's figures would give us a slight prepon- 
derance of males, while Liebermeister, in over 
2000 cases of typhoid, gives 1300 males and 750 
females. 

Unfortunately, I omitted to tabulate the number 
of cases arising in military practice, which I am 
sure is not inconsiderable; but while this will ac- 
count to some extent for the predominance of males, 
it could not be adduced in the cases of arthritis and 
dislocation, since most of these patients were chil- 
dren, yet the males were in the preponderance. 

10. To the surgeon the most interesting recent de- 
velopments are those relating to biliary and intestinal 
perforation. We may even take courage as to these 
formerly almost uniformly fatal complications. Of 
four cases of perforation of the gall-bladder thus far 
submitted to operation, three have recovered. Nat- 






CONCLUSIONS. 319 

urally, the outlook in intestinal perforation is far 
less encouraging, but it is far from hopeless. Of 
83 cases operated upon, 16 have recovered, or 19.3 
per cent. If, knowing the possibility of recovery, 
physicians more frequently call in the surgeon, and 
do so at once, the future will show better results. 

I can not too strongly urge that the essential mor- 
tality of operations for typhoid intestinal perforation 
is not accurately estimated by the mortality of all 
the cases (80.7 per cent.). The real mortality tints 
far is only 69.4 per cent. ; that is to say, the mor- 
tality of the cases operated on within practically the 
first twenty-four hours. After that nearly all hope 
is gone. The table on page 227 shows that, includ- 
ing case 64, operated on after twenty-six hours, 
there were, within this period, 36 cases with 1 1 re- 
coveries (30.6 per cent.). When every case of intes- 
tinal perforation (except the moribund) is operated 
upon within twenty-four hours, I believe that we shall 
save at least one-third of the cases and possibly more. 

11. The diagnosis is, in general, moderately easy. 
The danger is not that difficulty of diagnosis may 
obscure the case, but that the diseases may be en- 
tirely overlooked. They occur most frequently in 
parts of the body covered by the bedclothes ; parts 
which require time and trouble to expose and ex- 
amine in the routine of an ordinary visit. More- 
over, the patient is frequently so apathetic and in- 
sensible to pain that he does not complain, or, if he 
do so, it is ascribed to the ordinary pains so frequent 
in the belly and legs in such fevers, or else to the 
delirium itself. 

Hence, the most important hint I can give in the 



320 SURGERY OF TYPHOID FEVER. 

diagnosis — and where, indeed, does the same rule 
not hold good ? — is that time and trouble must be 
taken, and that no patient suffering from a continued 
fever, and especially from typhoid, should escape 
frequent, minute, complete, physical examinations, 
in which every part of the body from head to foot 
should be questioned. Especially should the physi- 
cal condition of the larynx, the belly, the legs, and 
the toes, and, in children, the hip-joint, be exactly as- 
certained. This should be done at least every sec- 
ond day; and that, too, not only in severe, but in 
mild cases, and not only during the fever, but es- 
pecially in early convalescence, for it is in just such 
mild and convalescent cases that the wariness of the 
doctor is the patient's surest reliance. Particularly 
should attention be paid to hoarseness or even the 
slightest change in the voice, and if these be pres- 
ent the larynx should be examined at once with the 
greatest care, from day to day, by the eye, the finger, 
and the laryngoscope, lest sudden edema or the 
more insidious and more fatal necrosis of the carti- 
lages be impending. The eye should seize upon any 
hindered movements, even without discomfort, and 
no complaint of pain should fall upon a deaf ear, 
especially if it be in the throat, the belly wall, the 
buttock, the hip-joint, the legs, or the toes. True, 
it may mean nothing. It may be the vagary of a 
wandering mind. But it may also be, as we have 
seen, the herald of the gravest dangers, whose attack 
may be entirely repelled or their force broken by 
heeding this timely warning. 

i 2. 'Wit prognosis is naturally unfavorable, yet not 
to the extent we would suppose from the addition or 



CONCL US IONS. 3 2 1 

sequence of such serious disease. Of 1037 cases in 
which the result is named, 456 died and 581 recov- 
ered — a mortality of 44 per cent. 

13. The treatment must be bold, but not rash ; 
conservative, but not timid ; prompt, but not hasty ; 
thorough, but not reckless. 



POSTSCRIPT. 

The following cases have been published since the 
foregoing pages were already in print, and are added 
to make the treatment of the subject as complete as 
possible. 

Dr. Hodenpyl's paper, referred to on page 45, has 
been published in the British Medical Journal for 
December 25, 1897, page 1850. 



Typhoid Infection without the Intestinal 
Lesions of Typhoid Fever (page 43). — Chiari, ■ 
before the Pathological Section of the Moscow Inter- 
national Medical Congress, read a paper on cases 
of typhoid infection without infection of the mesen- 
teric glands or the intestine. He characterizes such 
cases as " typhus-septicemia." He reported the 
folio wine case : 

Case LXI. — The Gruber-Widal serum reaction 
confirmed the diagnosis of typhoid, but at the 
necropsy no characteristic intestinal changes were 
found, but the bacteriological investigation showed 
the presence of typhoid bacilli. 

1 Centralbl. f. alleg. Pathol, and patholog. Anat., Oct. 15, 1897, viii, 790. 
21 



322 SURGERY OF TYPHOID FEVER. 

Case LXII. 1 — A man, age twenty-five, was 
admitted to the hospital, July 8, 1897, as an am ~ 
bulant case of typhoid fever. He had suffered 
with headache, loss of appetite, and general weak- 
ness. The abdomen was distended, tense, and 
tender. Fading rose spots were visible. The 
spleen was palpable ; bowels constipated. The 
pulse was dicrotic. The blood gave the typical 
serum reaction. From the 8th to the 13th he was 
semi-comatose. Just before death his temperature 
reached 106. 6°. Cultures made from the blood the 
day before death were sterile. He died on the 21st. 
The necropsy was made eight hours later by Drs. 
Adami and Nicholls. The mesenteric glands, espe- 
cially those about the ileo-cecal region, were en- 
larged, congested, and succulent. " The lowest 
three Peyer's patches of the ileum were very slightly 
raised above the general surface, but showed no 
signs of inflammation. The remaining Peyer's 
glands were normal. There was no evidence of ulcer- 
ation anywhere in the intestine nor any evidence of 
healed typhoidal lesions." By the microscope, 
clumps of the typhoid bacilli were found in the 
intestine and in the mesenteric glands. A section 
through one of Peyer's glands which presented 
slight swelling showed small clumps of bacilli re- 
sembling typhoid. The blood-serum taken at the 
necropsy gave the typical serum reaction. Cultures 
from the spleen and the liver showed the typhoid 
bacillus and reacted to the serum-test. All these 
tests were made by Nicholls and Adami indepen- 
dently, and agreed exactly. 



Osteomyelitis of the Skull and Abscess of 
the Brain (Chapter VIII, p. 169). — The following 

1 Nicholls and Keenan, Montreal Med. Jour., Jan., 1898, p. 9. 



CONCLUSIONS. 323 

case of presumed osteomyelitis and abscess of the 
brain following typhoid fever occurred in 1889, but, 
owing to its defective title, I discovered it too late to 
insert it in the proper place. 

Case LXIII. — Terrillon l reports the following 
case: On December 24, 1888, Richard was called 
to see a boy of thirteen with violent pain in the 
head, vomiting, and intense fever. After eight days 
his sickness apparently ceased, and it was believed 
that he had been ill of scarlet fever. Five days 
after defervescence — i. e.< January 3, 1889 — ne was 
seized with convulsions. The urine showed no 
albumin. The fever and the pain in the head re- 
turned, and he was delirious for five or six days. 
Richard was then convinced that the child's illness 
was typhoid fever. On the 20th of January con- 
valescence began, and appeared to be complete by 
February 1st. On February 14th he began to 
complain of pain in the left temple, where a slight 
swelling was found. On the 20th an incision was 
made, which evacuated only blood. On the 21st, 
aphasia and paralysis of the right arm were 
observed, with a temperature of 38 C. Terrillon 
first saw the child February 23d. He found marked 
tumefaction in the left temple, with fluctuation and 
surrounding edema. The boy was in a profound 
torpor. Paralysis of the right face and arm was still 
evident. An incision was immediately made over 
the left temple, evacuating a considerable amount of 
thick, grumous pus. The bone was denuded, and 
the base of the cavity lined with fungous granula- 
tions. On the 25th a temporary improvement which 
had taken place disappeared. The child was imme- 
diately trephined. The dura was not opened, but 
three punctures were made, and at the third, passing 
forward and downward, more than a tablespoonful 

1 Bull, et Mem. Soc. de Chir. Paris, 1889, n. s. xv, 555. 



324 SURGERY OF TYPHOID FEVER. 

of greenish, creamy pus was evacuated. An inci- 
sion was then made and drainage established. On 
awakening from the anesthesia he could move the 
right arm, and the facial paralysis had almost en- 
tirely disappeared. He was able also to pronounce 
several words. In spite of this apparent improve- 
ment, however, he soon became worse, and died on 
the 3d of March, five days after the operation. The 
conclusion of Terrillon was that an osteomyelitis of 
the bones of the skull had griven rise to both of the 
abscesses. 

Two very unfortunate omissions, however, are 
notable in the case : First, no necropsy was made, 
so that while the case was presumably one of 
typhoid, it is by no means certain ; and, secondly, 
and still more important, no bacteriological exami- 
nation was made, although the bacillus of Eberth 
had been demonstrated as the cause of typhoid 
nine years before. 

Suppuration Around the Pituitary Body with 
Thrombosis of the Right Sylvian Vein and 
Both Cavernous Sinuses (Chapter VIII, p. 169). 

Case LXIV. — The following case of this very 
unusual condition after typhoid fever is kindly fur- 
nished me by Dr. Joseph Sailer, of Philadelphia. A 
young man, twenty years of age, suffered a moderate 
attack of typhoid fever in the autumn of 1897, when 
under the care of Drs. Henry Morris and G. M. 
Marshall in St. Joseph's Hospital, Philadelphia. All 
the characteristic symptoms had been present, 
including the Widal serum reaction, at three different 
examinations. During defervescence he was sud- 
denly attacked by a severe chill, which lasted with 
intermissions for about forty-eight hours. During 
this period and three days later the Widal reaction 
was negative. Subsequently it reappeared, and was 
readily obtained in a dilution of 1 to 30. A few 






CONCLUSIONS. 



o-o 



days after his chill, swelling was noticed in the right 
parotid gland. This rapidly increased, and in a short 
time the patient developed bilateral exophthalmos, 
with considerable subconjunctival effusion. Fluc- 
tuation was then detected in the parotid gland ; the 
gland was incised and several ounces of extremely 
fetid pus removed. This was given me [Dr. Sailer] 
for examination, and found to contain a great variety 
of micro-organisms. It was not possible to isolate 
any, however, that resembled the typhoid bacillus. 
Death occurred two days later. I made the autopsy 
within five hours ; found a few typhoid ulcers in the 
ileum which were beginning to heal ; a purulent ex- 
udate in the left pleural cavity, also clue to a mixed 
infection, and a suppurative condition about the hypo- 
physis cerebri, with thrombosis of the right Sylvian 
vein and both cavernous sinuses. Both retro-bulbar 
spaces contained a large effusion of liquid. Cultures 
of the bacillus pyocyaneus were obtained from the 
mesenteric glands. In the thrombi of the cerebral 
veins a number of species of micro-organisms were 
found, all of which have not been identified, but none 
of which resembled the typhoid bacillus. Cultures 
from the spleen were negative. 



Cholecystitis following Typhoid Fever (Chap- 
ter XVI, p. 244). — The following case of probable 
perforation of the gall-bladder has also been pub- 
lished by Dr. James Bell in the Montreal Medical 
Journal for January, 1896. 

Case LXV. — Miss C, age thirty-five, at the end 
of the second week of typhoid fever was seized 
with pain, vomiting, and a fall of temperature to 
94.5 , early in the morning on September 21, 1897. 
The abdomen was opened September 24th, at 4.30 
p.m. There was no general peritonitis, but the 



326 SURGERY OF TYPHOID FEVER. 

gall-bladder was distended and covered with patches 
of lymph, as also were the lower border of the liver 
and adjacent coils of intestine. There was no per- 
foration. By aspiration he withdrew six ounces of 
pus, which showed the typhoid bacillus in pure cul- 
ture. The gall-bladder was then incised and 152 
gall-stones removed ; a drainage-tube was inserted 
and bile flowed freely. In the lower angle of the 
abdominal wound a drainage-tube and iodoform 
gauze packing were carried up along the under sur- 
face of the liver. She did well until the mornine of 
the 26th, when symptoms of perforative peritonitis 
set in, and she died at 4 a.m. on the morning of the 
27th. An incomplete post-mortem examination 
showed a general purulent peritonitis, and four gall- 
stones were removed from the lower angle of the 
wound. The small intestine showed the typical 
lesions of typhoid. " In the absence of a complete 
post-mortem examination of the abdomen, my [Dr. 
Bell's] interpretation of the sudden termination in 
this case is that ulceration of the deeper part of the 
gall-bladder or of the cystic duct had taken place 
into or upon the adjacent under surface of the liver, 
and that it was the bursting or emptying of this 
abscess cavity which set up the fatal peritonitis. In 
no other way can I account for the presence of the 
four gall-stones in the peritoneal cavity, as I am sure 
they did not escape into the abdomen at the time of 
the operation, and the steady flow of bile externally 
for hours after the fatal symptoms set in showed that 
there could not be any direct communication with the 
abdominal cavity. Moreover, the wound was exam- 
ined and the gall-bladder sutures found intact five 
hours after the onset of the symptoms." 



Leukemic Spleen following Typhoid Fever 
(Chapter XVII, p. 274). — While correcting the 



CONCLUSIONS. 327 

proofs, the following case, almost the duplicate of 
Case XLIX, page 275, came under my own obser- 
vation. Figure 4, illustrating that case, was practi- 
cally exactly duplicated in the present case. 

CaseLXV/.—E. L. P., of Mt. Holly, N. J., first 
consulted me, with Dr. R. H. Parsons of the same 
place, January 22, 1898. His age is thirty- three ; his 
average and present weight is 124 pounds. Three 
years ago he only weighed 95 pounds. His father 
is living and in oood health; his mother died of 
hemorrhage after a miscarriage. His paternal 
orandmother died of hemorrhage of the lungs at 
seventy-three ; his paternal grandfather is still 
living at ninety. His maternal grandmother died at 
eighty-one of old age ; his maternal grandfather of 
some unknown disease. For some two or three 
years he has suffered with alternate constipation, 
when he would often not have a movement for a 
week, and a loose condition of the bowels, when he 
would have two or three movements a day ; the 
latter gave him much relief. The patient has suf- 
fered from several attacks of grippe, notably a very 
severe attack in the spring of 1895. This was 
followed by typhoid fever, and from July to October, 
1895, by an attack of inflammatory rheumatism. 
On his recovery from the inflammatory rheumatism 
his weight was only 95 pounds. In July, 1895, while 
under treatment for the rheumatism, and shortly after 
his attack of typhoid fever, his attending physician 
discovered a lump in his left side, and pronounced it 
an enlarged spleen. Not long after his recovery 
from the rheumatism he had severe pain in the 
abdominal tumor, "so severe that he was almost 
crazy " for two or three weeks. From January to 
March, 1896, he was under the care of Dr. William 
Pepper, of Philadelphia, who confirmed the diagnosis 
of an enlarged and leukemic spleen. He has never 



328 SURGERY OF TYPHOID FEVER. 

had any blood in the urine or other indication of 
trouble with the kidney. For some time past he 
has been suffering daily from fever, his temperature 
rising to ioi° or 102 . In spite of this, however, 
ever since passing from Dr. Pepper's care he has 
been attending' to his business, and, on the whole, 
seems not to have lost much ground. An examina- 
tion of the abdomen shows a tumor almost identical 
with that shown in figure 4, page 276. An ex- 
amination of the blood made by Dr. Kyle gives the 
following result : 

Hemoglobin, 70 per cent. 

Red corpuscles per cubic mm., . . .4,066,000 

" " " " normal, 3,000,000 

White corpuscles per cubic mm., . . . 200,000 

The case being one of leukemic spleen, I declined 
to interfere surgically. 



APPENDIX. 



TONER LECTURE, NO. V. 



REPRINTED BY THE KIND PERMISSION OF THE 
SMITHSONIAN INSTITUTION. 



SMITHSONIAN MISCELLANEOUS COLLECTIONS 

300. 



THE TONER LECTURES 



INSTITUTED TO ENCOURAGE THE DISCOVERY OF NEW TRUTHS 
FOR THE ADVANCEMENT OF MEDICINE. 



Lecture V. 



ON THE SURGICAL COMPLICATIONS AND SEQUELS 
OF THE CONTINUED FEVERS. 



BY 

WILLIAM W. KEEN, M.D. 

OF PHILADELPHIA. 



Delivered February 17, 1876. 



WASHINGTON: 

SMITHSONIAN INSTITUTION. 
March, 1877. 



ADVERTISEMENT. 



The " Toner Lectures " have been instituted at Wash- 
ington, D. C, by Joseph M. Toner, M.D., who has placed 
in charge of a Board of Trustees, consisting of the Secre- 
tary of the Smithsonian Institution, the Surgeon-General 
of the United States Army, the Surgeon-General of the 
United States Navy, and the President of the Medical 
Society of the District of Columbia, a fund "the interest 
of which is to be applied for at least two annual memoirs 
or essays relative to some branch of medical science, and 
containing some new truth fully established by experiment 
or observation." 

As these lectures are intended to increase and diffuse 
knowledge, they have been accepted for publication by the 
Smithsonian Institution in its " Miscellaneous Collections." 

The First Lecture of this series was delivered March 
28, 1873, by Dr. J. J. Woodward, "On the Structure of 
Cancerous Tumors and the Mode in which Adjacent Parts 
are Invaded." Published by the Smithsonian Institution, 
November, 1873. 44 pp. 8vo. 

The Second Lecture was delivered April 22, 1874, by 
Dr. C. E. Brown-Sequard, " On the Dual Character of the 
Brain." Published by the Smithsonian Institution, January, 
1877. 25 pp. 8vo. 

The Third Lecture was delivered May 14, 1874, by 
Dr. J. M. Da Costa, " On Strain and Over-action of the 
Heart." Published by the Smithsonian Institution, August, 
1874. 32 pp. 8vo. 

The Fourth Lecture was delivered January 20, 1875, 
by Dr. Horatio C. Wood, " On a Study of the Nature 
and Mechanism of Fever." Published by the Smithsonian 
Institution, February, 1875. 48 pp. 8vo. 

Joseph Henry, 

Secretary Smithsonian Institution. 
Smithsonian Institution, 
Washington, April, i8yj. 



LECTURE V. 

Delivered February 17, 1&76. 

ON THE SURGICAL COMPLICATIONS AND SEQUELS 
OF THE CONTINUED FEVERS. 



By William W. Keen, M.D., 

OF PHILADELPHIA. 



The province of the physician and that of the surgeon 
arc, in general, sufficiently sharply defined and differenti- 
ated, yet they have many points of contact. While some 
diseases belong exclusively to the province of the one, and 
some to that of the other, other diseases may fall with 
equal propriety under the care of either practitioner. Still 
another class of cases, however, beginning in the domain 
of medicine, may terminate in that of surgery, and we 
may lack their complete history from the very fact of this 
division of their care and interest. 

Among the diseases classed as strictly medical, none de- 
serve the appellation more definitely than the continued 
fevers, and especially typhus and typhoid. Yet I hope 
to show that fevers are not infrequently the cause of the 
gravest and least expected surgical troubles, mention of 
which is generally omitted, even in our best text-books on 
medicine, still more rarely noticed in works on surgery, 
and, where noticed, it is only with the greatest brevity. 1 

1 " The cases of constitutional disease discovered by fever might serve to 
illustrate a large part of the convalescence of fever, a subject of the highest 
•interest and full of promise of utility to one who will carefully study it. The 
sequela? of scarlet fever are commonly enumerated ; those of t\phoid fever, 
especially those seen in surgical practice, are scarcely less numerous, but seem 
less known." Just as this is going to press, I find the above remarks by Sir 
James Paget, in his extremely interesting Clinical Lectures and Essays, 
London, 1875, p. 37S. 

333 



334 SURGERY OF TYPHOID FEVER. 

My attention having been called to the matter by sev- 
eral personal cases, I have been led to study the subject, 
and I desire now to record briefly the results of an exten- 
sive search of medical and surgical works, as well as the 
records of individual cases, in the hope that by grouping 
together many isolated instances I may be able to con- 
tribute somewhat to our exact knowledge of the surgical 
complications and sequels of the continued fevers, both as to 
their causes, the means of their early recognition, the best 
methods of treatment, and, if possible, that still higher ob- 
ject — the averting of dangers which otherwise may prove 
disastrous to health, and too often to life itself. 

The exanthematous fevers are better known as causes of 
surgical troubles, and I have therefore carefully excluded 
them, as well as a few cases following intermittent fevers. 

I shall omit entirely all well-known results of a semi- 
surgical character, such as hemorrhage from the nose and 
bowels ; peritonitis, with or without perforation ; erysipelas, 
a not infrequent complication about the face or when bed- 
sores exist ; and cases of thrombosis of the veins, which 
cause a variety of phlegmasia deserving a more extended 
study than it has yet received. Bedsores and the ordi- 
nary abscesses are too well known to demand other than 
passing allusions. Much as I regret to do so, I must also 
omit, from want of time, the consideration of the forms of 
disease which especially interest the ophthalmic surgeon. 
Ulceration and perforation of the cornea are briefly, but I 
may say completely, treated by Trousseau. 1 Post-febrile 
ophthalmia, or amaurosis, — a peculiar retino-choroiditis 
which follows only relapsing fever, first described by Hew- 
son, in 1814, and by Wallace in 1827, — has been so care- 
fully studied of late by ophthalmic writers as to leave but 
little further to be said. 

I shall include only such cases as diseases of the joints ; 
edema glottidis and necrosis of the cartilages of the larynx, 
which often require tracheotomy ; necrosis of the bones ; 
gangrene of the extremities and other parts ; fistulae of 
various kinds, and the like. 

The records of many cases are extremely imperfect ; some, 
in fact, are mere allusions, and I have been compelled, there - 

1 Clinique Med. de l'Hotel-Dieu, 2d ed., p. 271, and Gaz. des Hop., 1856, 
170. 



APPENDIX. 335 

fore, in tabulating them, to conic as near the truth as may 
be. The frequency of many symptoms is therefore greater 

than appears from my tables. Especially is it difficult to 
discriminate between typhus and typhoid fevers as causes. 
The earlier cases, before the essential abdominal lesion of 
typhoid was recognized, are all classed as typhus, and even 
to-day many cases, especially in German books and jour- 
nals, are briefly called " typhus," meaning " typhus 
abdominalis " — i. e. t typhoid. If any error exist, therefore, 
it will consist in assigning too many cases to typhus proper, 
for I did not feel permitted to go back of the record unless 
plainly authorized to do so by the history or the post- 
mortem. 

I. Diseases of the Joints. 

Two forms of disease of the joints are found : first, a poly- 
articular inflammation, which may assume either a rheu- 
matic or a pyemic form ; and, secondly, a monarticular 
inflammation. 

The rheumatic variety I shall at once dismiss. The 
pyemic form of inflammation is not very common, for Mur- 
chison. with his immense experience in the London Fever 
Hospital, has seen but one case. It follows the usual 
course of pyemia, both in its symptoms and its usually fatal 
issue. Huss and others have referred it to suppurative 
phlebitis from bedsores, parotitis, etc., but it has been ob- 
served in cases in which no such complication existed. 
Pyemic arthritis, like the gangrene frcm pressure, parotitis, 
etc., is most apt to occur in severe cases, in which the blocd 
change is at its maximum, and the "typhous crasis," as 
Stokes has expressed it, possibly becomes converted into 
pyemia. 

It is, however, the monarticular form which will most 
interest us. It affects the larger joints, such as the elbow 
and shoulder, the ankle and knee, but above all the hip. 
The pain is usually slight. The swelling is generally 
readily observed in all joints except the hip and the shoul- 
der, where it is probably obscured by the muscular masses 
about these joints combined with the tardy increase in the 
swelling. Usually it arises spontaneously, but occasionally 
from periostitis or necrosis extending into the joint. It 
rarely produces suppurative or fistulous openings. The 



33 6 SURGERY OF TYPHOID FEVER. 

result is, therefore, generally a gradual return to usefulness, 
although in three cases I have found ankylosis. Of 43 
cases, the lower extremities were affected in 39, the upper 
in only seven, three of the cases involving a joint in both, 
for occasionally two large joints are affected at once. Ar- 
thritis, therefore, resembles other surgical febrile affections, 
such as gangrene, necrosis, etc., in affecting mainly the 
lower extremities, as do also thrombosis and the ordinary 
edema. The frequency of these joint troubles is not great. 
According to Giiterbock, 1 in a series of years in the Charite 
(Berlin) and the Hamburg Hospitals, not a case occurred, 
and in the Vienna General Hospital, from 1868 to 1 871, 
only two cases among 3130. Murchison does not even 
name this complication at all, nor do any other of our text- 
books, either on surgery or practice, except a few lines by 
Volkmann in Pitha and Billroth' s Handbuch. Giiterbock 
and Hell wig 2 are the only authors who have treated them at 
all fully. Yet that they are of great importance, and demand 
our utmost attention, will be seen at once when we consider 
that of the 43 cases named, spontaneous dislocations oc- 
curred 27 times in the hip, twice in the shoulder^ and once 
in the knee. 

These dislocations require more particular notice. From 
their similarity to febrile arthritis in the same and other 
joints their pathology seems clear, although — in singular 
contrast to the strangely fatal laryngeal stenosis I shall 
soon consider — not a single death has occurred, and there- 
fore no post-mortem verification has been possible. They 
belong- to the class of " distention luxations." That the 
cause is not the specific poison is evident, since similar 
results follow other and dissimilar diseases, such as loco- 
motor ataxia, the exanthematous fevers, hemiplegia, sciatica, 
and rheumatism, as pointed out by Stanley in 1841. 3 

Usually, in the period of convalescence, following there- 
fore the prolonged exhaustion, there arises a subacute 
synovitis, with a gradual serous distention of the capsular 
ligament, which, having reached a certain point, may slowly 

1 Ueber spontan. Luxat. und einige ander. Gelenkkrankh. bei Ileotyphus, 
Langenbeck's Archiv, xvi, ^8. 

2 Ueber die Affect, des Hiiftgelenk. bei Typhus, Marburg, 1856. 

3 On Dislocation, Espec. of the Hip-joint. Med.-Chir. Trans., xxiv, 123. 
See also Malgaigne, Fract. and Disloc, Paris, 1855, ii, pp. 218-226, 882-887. 



APPENDIX. 337 

subside, and no further evil follow. In three cases, how- 
ever, this burst externally, producing sinuses, but in none 
of them was the discharge purulent. The main result is a 
slow, generally unperceived, elongation of the ligaments, — 
e.g. t of the hip, — with perhaps also a swelling of the so- 
called gland at the bottom of the acetabulum. This dis- 
tention will spend its force mainly posteriorly, since the 
inverted Y-ligament reinforces the capsular ligament in 
front. Given this condition, the slightest force will dislo- 
cate the head of the femur upward and backward on the 
dorsum of the ilium. In one case a fall to the floor pro- 
duced it, in three others turning over in bed, and twice the 
lifting of the patient in the arms from one bed to another. 
But in all the other 21 cases no cause was assignable, and 
it is, therefore, likely that it was mere muscular contrac- 
tion which becomes, at the time when these occur, more 
vigorous as health gradually returns. Seitz has recorded 
one of the most remarkable cases, in which, from extensive 
bedsores, the abdominal decubitus was maintained for 
nearly a month, and he supposes that this was the imme- 
diate cause of the dislocation. But as in no other case is 
this posture noted, it can not be regarded as correct. In- 
deed, if posture have any influence, as the dislocation is 
generally if not always iliac the dorsal decubitus would be 
the most favorable for its production. In one of the 
shoulder cases a subcoracoid luxation was caused by the 
patient's assuming the erect posture. Gravity had here 
probably some influence, together with the muscular exer- 
tion. The dislocation of the knee also was posterior. 

A remarkable case, corroborative of the non-specific 
character of the lesion and the probable influence of 
gravity, I have lately seen in the service of Dr. Wm. G. 
Porter, at St. Mary's Hospital. The child was about two 
years of age, greatly exhausted from malnutrition, and for 
about six weeks w T as kept alive by inunctions of sweet oil, 
no other nourishment whatever being given. It had large 
abscesses in different parts of the body, and at present has 
necrosis of the left humerus. Early in the period of 
returning strength, and before the necrosis appeared, spon- 
taneous luxation of the left humerus into the axilla oc- 
curred. It was easily reduced by manipulation, and has 
not since recurred. 



338 SURGERY OF TYPHOID FEVER. 

Typhoid was noted as the preceding fever in 1 5 and 
typhus in 7 of the hip cases. Sex has a marked pre- 
disposing influence in this, as we shall find in other diseases, 
for of 23 cases, 15 were males and only 8 females. The 
age at which they occur is still more noteworthy : 15 were 
under fifteen years, 6 from fifteen to twenty, 1 was thirty, 
and one was sixty-one years old; that is, 21 out of 23 
were under twenty years old. The analogy to coxalgia, it 
will be observed, is therefore very marked. Usually they 
were single dislocations, 6 being on the right side and 6 
on the left ; but in 3 cases dislocation of both hips oc- 
curred. 

From the apathetic condition of the patient in some cases, 
the subacute nature of the lesion, the absence or slightness 
of the pain, the masking of the swelling by even the wasted 
muscles about the joint, and, above all, the want of knowl- 
edge of cause or probability of the dislocation, and therefore 
the neglect to examine the parts thoroughly, it is not sur- 
prising that this threatening evil should have been often 
unobserved. In 9 — that is, one-third — of the cases it is dis- 
tinctly stated that the actual dislocation was the first fact 
observed, and in most of the others this is probably true. 

The date at which the dislocation was, at least, observed, 
was generally after the third week. One case occurred in 
the first week, 4 in the second, and 9 in the fourth week or 
later — that is, during distinct convalescence. Pain was ex- 
perienced in 13 cases. Usually it was not severe, nor 
was it always strictly localized in the hip, but sometimes 
extended to the entire leg. In only two cases was it 
referred to the knee, thus differing markedly from the well- 
known coxalgic knee pain. Swelling is only distinctly 
stated in 6 cases, though probably present here as in other 
joints, but either unobserved or often unrecorded in the 
brief statements I have often found. The variety of the 
dislocation is not named in 10, but as in all the other 17 
it was iliac, there is good reason to believe that this is prob- 
ably always the case. Shortening is recorded in 1 1 cases, 
and where the amount is named was generally 1 T / 2 to 2 
inches. In 5 cases the rotation was inward, in 2 outward, 
and in 2 of the 3 double dislocations both legs were rotated 
in the same direction, — that is, right or left, — thus producing 
a peculiar deformity when compared with the apparently 






APPENDIX. 339 

reversely rotated body. The head of the bone in 4 eases 
was freely movable in all directions. This mobility of the 
head and the singular diversity in the rotation of the limb 
are additional reasons in favor of the distention theory of its 
pathology. Flexion and adduction Dr. Sayre lias shown 
to be the position of the limb which produces the greatest 
capacity of the capsular ligament of the hip, and we ought 
to see this position, therefore, as a rule, in distention 
luxations. But I only find two cases in which there were 
adduction and flexion. In the other cases the position is 
not stated, except in one in which the limb was extended. 

As to treatment, reduction is generally easy when the 
luxation is discovered early, but if the discovery or treat- 
ment be tardy it is always difficult and often impossible. 
In 11 cases reduction was successfully accomplished — seven 
times by manipulation, twice by extension, and twice by 
both means. In 8 cases reduction was not effected, and in 
8 the result is not stated. Only 2 cases of recurrence 
of the luxation are noted, a rather surprising fact in view 
of the relaxation of the distended tissues ; but its pos- 
sibility should be borne in mind and guarded against by the 
same prophylactic means that I will name directly. No 
snap is heard on reduction, all tension and suction-power of 
the joint being lost. Even atter reduction the leg may be 
somewhat longer than the other, owing, probably, to the 
distention, to the swollen articular gland, and possibly in 
old cases to interstitial changes in the neck of the femur. 

The question of prophylaxis is perhaps the most impor- 
tant of all, and the indications are clear. First, a careful 
watching and repeated examination of the hip-joint, espe- 
cially in children, to detect any effusion. If any exist, the 
position of the leg becomes of the greatest possible impor- 
tance. As adduction and internal rotation favor spontaneous 
dislocation, the leg should be kept in abduction and exter- 
nal rotation. The first indication is easily fulfilled by two 
lateral sandbags, which may be bridged across in front at 
intervals by a bandage, to keep the leg at rest between 
them, or by lateral splints. The foot may be kept in 
external rotation by bandages or adhesive plaster fastened 
to the external sandbag or splint. If the effusion threaten 
to produce dislocation, it may well be a question whether 
aspiration would not afford a safe and efficient means of 
prophylaxis. 



140 SURGERY OF TYPHOID FEVER. 



II. Diseases of the Bones. 

A popular name for necrosis is "fever sore," but, as 
Nathan Smith long since pointed out, more because it 
caused fever than because it was caused by fever. That it 
does follow fever and is caused by it is certainly true, but 
it is not a very frequent though a very important sequel. 
I have collected thus far 50 cases of necrosis proper follow- 
ing continued fevers, but among these are 19 reported by 
one single author, — Whately, — the histories of which are 
exceedingly brief and unsatisfactory. He states, indeed, 
that he has seen 30 cases — an incredible statement, I think, 
in view of the fact that from all other sources, after an 
extended search, I can only gather 31 more. "Fever" 
with him, however, may include a very wide range. One 
element of unavoidable uncertainty in the history is seen at 
once. The osseous disease usually falls under the eye of 
the surgeon at a period distinctly subsequent to the fever, 
and, knowing nothing personally as to the previous medi- 
cal history, he must depend upon the statement of the 
patient — often a most unreliable means of information. 

Two causes for such necroses and other forms of disease, 
such as periostitis and caries, are to be found : first, throm- 
bosis, or in some cases possibly embolism ; and, secondly, 
absolute inanition or want of nutrition. 

The role assigned of late to the marrow together with 
the spleen as a source of the red corpuscles, would seem to 
be confirmed by the similarity of the changes observed by 
Ponfick x and others in the spleen and marrow in typhoid. 
In later convalescence, or shortly after recovery, we find 
in the marrow many mother-cells holding numerous blood- 
cells, enormous masses of large cells filled with pigment 
in complete analogy with the observed metamorphoses of 
extravasated blood. These are especially seen at the sides 
of the cavernous veins, and must retard still further a 
circulation already impaired in force by a weakened heart. 
Nutrition is here at its lowest ebb, and as the vessels, from 
the nature of the tissue in which they run, can not enlarge 
in proportion to the needs of the circulation, and are them- 

1 Ueber die sympathischen Krankh. des Knochenmarks bei inneren 
Krankh., Virchow's Archiv, lvi, 524. Cf. also Anatom. Studien iiber den 
Feb. Recurrens, Virchow's Archiv, 1874, lx, 153. 



APPENDIX. 341 

selves more or less involved in fatty degeneration, we may 

readily understand how the lack of nutrition alone, as in 
Dr. Porter's case previously cited, would cause gangrene ol 
the bone even more readily than in the soft parts, in which 
we know it to be so common. 

That the bones should suffer from vascular clots, and 
especially the bones of the lower extremities, where such 
clots are most frequent, as we shall see, in gangrene, is 
probable both from analogy and experiment, and from 
one case in which it has been actually observed in 
typhoid. 1 There is no reason to suppose, when throm- 
bosis is so frequent elsewhere, that the bones would escape. 
Virchow has shown that in relapsing fever we frequently 
have infarcts in the marrow. Volkmann 2 gives an ex- 
cellent case and illustration of necrosis of the tibia and 
talus from embolism, the result of endocarditis. We need 
a few similarly exact observations in cases of necrosis from 
fever, in which death or amputation affords the desired 
opportunity to settle the question positively ; but generally 
the examination, if made at all, is of the most superficial 
character. Hartmann 3 has shown, experimentally, that 
obliteration of the nutritious artery causes necrosis of the 
inner lamella of bone — a strong point it must be admitted, 
in favor of Whately's theory that after fever the result is 
not ordinary necrosis, but a central necrosis of the inner 
lamella which he limits to the tibia. Blocking of the veins 
is evidently not so dangerous in bones as blocking of the 
arteries, since the collateral venous circulation, especially 
toward the extremities, is abundant, while the collateral 
arterial circulation is scanty. 

I have found 69 cases of diseases of bone following con- 
tinued fevers. Of these, 50 were cases of necrosis, 12 of 
caries, 3 of periostitis, and 4 of indeterminate or doubtful 
nature. Three cases of necrosis following typhoid combined 
with small-pox I have excluded. Typhoid, as usual, claims 
the larger share ; for of 41 cases, 37 followed typhoid and 

1 See Meusel's case, p. 344. 

2 Pitha and Billroth' s Handbuch, Bd. ii, Abth. i, Lief, i, p. 287 ; and 
Langenbeck's Archiv, 1864, v, 330. See also Molliere, Lyon Med., 1870, 
pp. 12, 149, 256; 1871, p. 38. 

3 Nekrose herbeigefiihrt durch Verstopfung des Foram. nutrit., Virch. 
Archiv, viii, 114. 



342 SURGERY OF TYPHOID FEVER. 

only 4 followed typhus. Males also are in the preponder- 
ance, counting 38 to 14 females. Age has not a very marked 
influence, as 19 were under twenty years, 11 from twenty 
to thirty, 1 1 from thirty to forty, and 5 over forty. 
Scarcely any region of the body escapes : 22 cases in- 
volved the head, 7 the trunk, 6 the upper extremities, and 
42 the lower, a result strikingly in accord with the cases of 
arthritis and gangrene. In the head I have found 12 cases 
of necrosis of the alveoli and jaws. Among these per- 
haps the most remarkable, although somewhat doubtful, 
case is the one I saw in a soldier at Frederick, Maryland, 
in 1862, in which, after typhoid fever followed by pneu- 
monia, the entire right upper jaw with a part of the palate 
bone and the intermaxillary bone necrosed and separated. 
The case is remarkable, both from its being a striking 
example of the limitation of disease by the embryonic 
development, 1 and also from the extraordinary series of 
operations subsequently done by Dr. Gurdon Buck, of 
New York, 2 to remedy the frightful deformity which had 
been produced. It is but proper to say that the man was 
reported to have taken about two drams of various mer- 
curials during his preceding illness ; but from the facts I 
have stated, as well as his scanty history, I think it toler- 
ably clear that the fever, and not the mercury, caused the 
necrosis. Mercury or syphilis complicated two or three 
of the other cases I have tabulated, but they were not, 
apparently at least, the cause of the trouble. 

Mr. Salter 3 has pointed out the relation of alveolar 
necrosis to the eruptive fevers, especially scarlet fever, and 
believes that as these structures are dermal in character 
they partake with the skin in the eruptive mischief. While 
this relation remains undisturbed, yet I do not think the 
necrosis exists as a specific sequel of these fevers only. 
Of the 12 cases cited, 7 occurred as follows: 1 at six- 
teen, 1 at twelve, and 5 at ten years of age and under — 
that is, during the period of dental development and 

1 H. Allen, Studies in the Facial Region, Phila. , 1875, nas specially- 
called attention to this point. 

2 Trans. N. Y. State Med. Soc, 1864, p. 173; Circ. No. 6, S. G. O. 
Surg. Sec, Spec. 557, p. 53; Med. and Surg. Hist. War of the Rebel., Pt. i, 
Surg, vol., pp. 375-377, and Buck on Reparative Surgery. 

3 Holmes' Syst. Surgery, 1st ed., vol. iv, p. 50. 



APPENDIX. 343 

growth. That such cases arc more frequent in the exan- 
themata is natural when we consider the relative infre- 
quency of the continued fevers under fifteen years of age. 

The period at which these diseases of the bones arise 
varies greatly. Of 47 cases, 10 arose in the first two weeks, 
27 in from three to six weeks, and the remaining 10 fol- 
lowed often months after the fever. The earlier cases in- 
clude, probably, most of those from clots, and the later 
ones those arising from enfeebled nutrition, whose effects, 
especially in structures which vary so slowly as the bones, 
may readily extend over such long periods. 

Especially does this enfeebled nutrition show itself in 
cases where too early strain is put upon the parts and justi- 
fies the remark of Aitken that " no man can be considered 
fit for work or for general military service for three or four 
months after an attack of severe typhoid fever." The fol- 
lowing case illustrates the wide-spread mischief that may 
follow in the osseous system when put to the test by labor, 
months and even years after such a fever. 

[For the full history of this case, see Case IX, H. W., 

P- I2 3-] 

The symptoms need scarcely be alluded to, for they are 
those of ordinary necrosis, although Whately endeavors to 
differentiate them. In 13 cases of necrosis of the long 
bones other than Whately's in which the description en- 
ables me to judge, I find only 3 distinct cases of central 
necrosis, x and these differ in no especial manner from 
other cases. That it is limited to the tibia, as asserted by 
Whately, is disproved by the fact that of yy bones affected, 
the tibia w r as attacked only 30 times, including in these the 
19 reported by Whately. 

The results of necrosis vary with the situation. The 

1 The third of these eases I have had in private practice while the MS. is 
passing through the press. A. W., a rather feehle girl, age eleven, was taken 
sick with typhoid May io, 1876. After three to four weeks in bed she began 
to walk, but soon had to stop on account of weakness, and especially of pain 
in her left tibia. After three weeks' poulticing it broke in two places, and has 
discharged ever since. I saw her first in December, 1876, and found two 
small sinuses which extended into the bone, but no dead bone had ever been 
discharged. After building up her general health by tonics and cod-liver oil, 
on February 17. 1 87 7, I operated on the bone, using Esmarch's apparatus in 
the manner I have suggested (Phila. Med. Times, Sept. 26, 1874), and after 
making an opening into the medullary canal with the chisel and gouge, I 
removed a small, loose spicula of necrosed bone (central necrosis) ^ of an 
inch long. At this date, March 5, 1877, she is doing well. 



344 



SURGERY OF TYPHOID FEVER. 



ordinary sinuses, etc., I need not mention further. If in 
the sacrum, coccyx, or innominate bone, perineal fistulse 
may result, of which I have found three cases. If in the 
mastoid or petrous bone, the brain and its membranes may 
be involved. The following resume of the case of Meusel 
is of especial interest, as it throws so much light on the 
cause of the necrosis, the clot in the meningea mag-na, and 
is as extraordinary for the audacity of the treatment as 
for the success of the result : 

A student in the g-vmnasium. age nineteen, at Easter, in 




Fig. i. — Necrosis of frontal (A), parietal (B), and greater wing of sphenoid 
(C) bones, following typhoid. In B and C the grooves for the middle menin- 
geal artery and its branches are seen. Natural size. (Meusel, Deutsche 
Klinik, 1872, page 266.) 



1868, had an attack of typhoid fever, went home when 
convalescent, but did not improve, and suffered much from 
headache. In August, four months after the fever, he had 
a large fluctuating abscess over the right parietal region, 
which was opened, and dead bone found. By October 1st 
the bone was loose, and on the 5th an incision of three 
inches was made and a loose piece of the frontal was re- 
moved. The rest of the dead bone was firm, but the 



APPENDIX. 345 

incision was extended backward until the whole of the 

necrosed portion was exposed. It was then carefully 
chiseled loose and separated at the squamous suture. At 
the anterior inferior angle the necrosis was there found to 
extend on the internal surface only ; with a fine chisel 
this internal lamella, a piece l l / 2 X 2 cm., was chiseled 
away from the great wing of the sphenoid. In it was a 
groove in which lay the anterior branch of the middle 
meningeal, filled with the detritus of a clot. The whole 
piece was 5^> X 9 cm. The dura mater was but slightly 
injected. The scalp and the dura mater united, and in 
fourteen days he was nearly well, having recommenced 
his Latin and Greek with the greatest zest eight days after 
the operation. Two small pieces of loose bone afterward 
caused threatening symptoms, but improvement followed 
immediately upon their discharge. In March he was en- 
tirely well, and went to Gottingen to study philology at 
the University. Epileptiform attacks followed during 1869, 
but then disappeared, and had not reappeared in 1872. 

As to treatment, the ordinary operation for the removal 
of necrosed bone is to be done at the proper time, especial 
care being taken to remove any small central sequestrum. 
Occasionally the disease of the bone may cause extensive 
disease in the soft parts, or may extend to a neighboring 
joint, though either complication is rare. Amputation then 
becomes imperative. Only four such amputations occurred 
in the cases reported ; two died, one recovered, and one 
was under treatment. About the face not infrequently 
extensive plastic operations are required. 

III. Diseases of the Larynx. 

The laryngeal complications are noted very briefly by 
several medical writers, such as Murchison, Flint, Lieber- 
meister, Griesinger, etc., but it is mainly the laryngeal 
ulcers themselves which are treated of, their surgical 
results being scarcely mentioned. Gross and Gray barely 
allude to typhoid as a cause of edema glottidis. Even 
systematic writers on the larynx scarcely notice them. 
Gibb x and Ruble 2 refer to two or three cases. Cohen 

1 Dis. of the Throat and Windpipe, 2d ed., 292-294. 

2 Die Kehlkopfskrankh., Berlin, 1861, 157, 257, and Fig. 2. 



34 6 SURGERY OF TYPHOID FEVER. 

simply names fever. Tiirck 1 gives, however, eight valuable 
cases. I have collected 169 cases, of which at least 67 
(and probably many more) certainly involved the cartilages 
themselves. 

The troubles which may demand surgical interference 
are all allied, and are the result of a low grade of inflam- 
mation. The entire respiratory mucous membrane (as is 
shown by the frequency of bronchitis) is in a more or less 
catarrhal condition, like that of the bowels, and occasion- 
ally other mucous membranes, such as those of the gall- 
bladder, urinary bladder, and vagina. It is not, therefore, 
a matter of surprise that serious trouble should arise in 
the larynx, especially as slight variations in its mechanical 
condition gravely embarrass so vital a function as respira- 
tion. 

Pathologically, the troubles may be grouped into three 
varieties — viz.: (1) Edematous laryngitis ; (2) ulcerative 
laryngitis ; (3) laryngeal perichondritis. Practically it is 
often exceedingly difficult to separate these various forms, 
even at the post-mortem, so far do they overlap each 
other. Edema may exist alone or it may result from either 
of the others ; ulceration may march steadily deeper until 
the cartilages are involved ; or the perichondritis may pro- 
duce an abscess which will burst, and so form an ulcer. 
How much more difficult, nay often impossible, then, is it 
to diagnosticate precisely the form of the disease, when, 
happily, the patient recovers. Dyspnea, suffocation, — this 
is the one great overshadowing clinical fact which groups 
them all together, whatever the form of the disease or of 
the preceding fever. 

That simple asthenic edema may arise just as edema of 
the lower extremities is not only probable but has been pos- 
itively observed by Emmet 2 and Buck. 3 It has also been 
observed after diarrhea, bronchitis, and other diseases ; but 
this is a much rarer form than those cases in which it is 
secondary to erysipelas, or parotitis, or laryngeal ulcers, 
often of small extent. I can not help suspecting, also, 
very strongly that more careful future examinations will 

1 Klinik d. Kehlkopf., Wien, 1866, 215-235. 

2 Amer. Jour. Med. Sci., July, 1856, xxxii, 63. 

3 Trans. Amer. Med. Assoc, 1848, 135. 



A r pen D IX. 347 

show in not a few cases that local venous thrombosis has 
been the cause of the edema. 

The other two forms especially merge into each other. 
Rokitansky believes that the ulcers are a peculiar form of 
typhus — the so-called laryngo-typhus. Others, and I cer- 
tainly agree with them, do not believe that they are specific 
in their origin, but belong "to the common cortege of 
septic diseases" and other allied disorders in which the 
low grade of inflammation readily runs into ulceration, and 
even into local gangrene. How much influence local stasis 
of the blood or even clots in the vessels may have has not 
been carefully investigated, but I believe them to be no 
unimportant factors. 

These ulcers are sometimes very common. Thus, Grie- 
singer 1 met with them in 31 out of 118 autopsies, Hoff- 
mann 2 in 28 out of 250, and Louis believes that "if found 
on the body of one who has died of an acute disease, they will 
establish with nearly perfect certainty, and without going 
any further, that the affection is typhoid fever." At other 
times the\- are so rare that in nearly 13,000 typhus cases 
at the London Fever Hospital, Murchison records but 21 
of laryngitis, of whom 8 died ; and in typhoid he has only 
seen three or four cases. 

Where the cartilages are involved, Moritz-Haller 3 and 
others believe that it follows the ulceration which destroys 
the mucous membrane and eats down to the cartilages, 
while Sestier 4 has gone so far as to declare that the ulcers 
which accompany perichondritis are not primary but in 
all cases secondary. Both, I believe, are right, but both 
go too far. So far as the history and post-mortem appear- 
ances would enable me to judge, I have found in 20 cases 
that the perichondritis preceded the ulcers and caused 
them, while in 10 cases the ulceration had caused the 
perichondritis. In cases of perichondritis in which death 
takes place early, there is no opening in the mucous mem- 
brane, but a submucous abscess will be found surrounding 
the necrosed cartilage. If death takes place at a later 
date, a small opening will exist, through which the probe 

1 Infectionskrankh., 1857. Bd. ii, Abth. ii, s. 160. 

2 Verand. d. Organ, beim Abdom. Typhus. 

3 Oesterr. Zeitschr. prakt. Heilkunde, 1856, No. 19. 

4 Arch. Gen., 1850, 4me ser. xxxiii, 385 ; xxiv, 35, 297, 441. 



34^ SURGERY OF TYPHOID FEVER. 

will enter into a much larger cavity. In other cases the 
surface mischief will be by far the most widely spread, the 
ulcers being roughly conical, involving not only the mucous 
membrane, but eating deeply down to the cartilages. Simi- 
lar necrosis of the nasal cartilages also sometimes results 
from fever. 

Those cases in which there is considerable cough, or the 
patient in his delirium has cried aloud, or sung much, or 
those in which, after distinct convalescence, there has been 
exposure to wet and cold, are predisposed to laryngeal 
troubles. They are exceedingly rare in children. In 94 
cases in which the age is recorded, I have found but 6 
under fifteen years of age, 60 from fifteen to twenty-five, 
and 28 above twenty-five years. Sex is potent here as in 
the other diseases considered. Lisfranc thought them 
more common in women than in men, but of 1 10 cases, I 
find 86 in men and only 24 in women, or 3^ to 1. 

The cause of the stenosis is various. It may be : (1) 
from edema ; (2) the swelling produced by the abscess about 
the cartilage ; (3) the sides of the glottis may fall together 
if the cricoid be destroyed and in pieces ; (4) the perma- 
nent approximation of one or, more rarely, of both, vocal 
chords from destruction of the fixed points of origin of the 
muscles ; (5) as in two remarkable cases given by Hoff- 
mann, 1 shreds of sloughing tissue, on which blood coagu- 
lates, may form a sort of polyp, which suffocates the patient 
even in spite of tracheotomy (Fig. 2). 

The seat of the stenosis is threefold. Most frequently 
(25 cases) it is supraglottic — that is, in the epiglottis and 
ary-epiglottidean folds, especially where the edema is pri- 
mary, or where it is caused by ulceration or arytenoid peri- 
chondritis. The next most frequent site is subglottic — i. e., 
about the cricoid (22 cases). This is always, I believe, the 
result of cricoid necrosis or perichondritis. Russell 2 re- 
ports two cases following typhus, which he regards as 
examples of Gibb's " subglottic edema." That the second 
was a case of ulceration and perichondritis is quite certain 
from the history, and most likely the other was too. The 
larynx was normal down to the chords, tracheotomy res- 
cued both when suffocation was imminent, and both were 

1 Op. cit., pp. 253 and 255. 

2 Glasgow Med. Jour., Feb., 187 1, 209. 



APPENDIX. 



349 



followed by stricture, requiring the permanent use of the 
cannula. The least frequent site of the edema is in the 
glottis proper, since edema of the vocal chords is named 
but nine times. 

The date of the development is generally here, too, in the 
later fever, or more frequently in distinct convalescence. 
Of 102 cases only 4 occurred in the first week, 13 in the 
second, 19 in the third, and 66 from four weeks to two 
months. They follow typhoid far more frequently than 
typhus, in the proportion of 106 to 49, some of the latter 






Fig. 2. — Laryngeal ulcer after typhoid. Polypoid hematoma hanging 
from it and causing death by suffocation after tracheotomy, a, upper end of 
incision. The smaller cut, b, is a section of the hematoma showing its two 
layers, the center consisting of shreds of dead tissue hanging from the ulcer, 
and the outer layer of clotted blood. (Hoffmann, Verand. d. Organ, beim 
Abdom. Typhus, Tafel v, Fig. 16.) 



being probably really typhoid, while 14 arose from other 
forms of continued fever. 

The position of the ulcers in the larynx is noteworthy. 
Wherever they may be, from the arytenoid to the cricoid, 
they are almost invariably posterior. Rheiner x has shown 
that the posterior wall of the larynx is the richest in ves- 
sels, and that ossification begins here often as early as the 
twentieth year. Here, then, we should expect the most 
frequent inflammations and thrombosis of the smaller ves- 

1 Beitrage zur Histologic des Kehlkopfs ; YViirzberg, 1852. 



350 



SURGERY OF TYPHOID FEVER. 



sels ; and when we add to this the effect of gravity, from 
the continuous dorsal position, and the mechanical effects 
of frequent use of the voice, and, therefore, repeated move- 
ment of the arytenoid cartilages in some delirious cases, we 
have a sufficient explanation of the phenomenon. Emphy- 
sema of the neck and trunk is an occasional result of such 
ulcers where they penetrate the mucous membrane. This 
was first pointed out by Wilks. 1 Other cases are reported 
by Steiner 2 and Loeschner. 3 All three were children. 




Fig. 3. — Perichondritis laryngea following typhoid. Ulcers on the pos- 
terior wall of the larynx. At a, a piece of the necrosed left arytenoid cartilage 
shows. (Tiirck, Krankh. des Kehlkopfes, p. 216, Fig. 78.) 



Necrosis of the cartilages is the most important form to 
recognize, in consequence of its excessive gravity ; for, of 
56 cases in which the result is given, 54 died. One recov- 
ered after tracheotomy, 4 and one without it. 5 We can 
scarcely agree with Tiirck, therefore, that the prognosis is 
" doubtful." The seat of the necrosis in the majority of 
the cases is the cricoid (38 times), next, the arytenoids (19 



1 Med. Times and Gaz., 1862, ii, 276, and Trans. Path. Soc, London, 
1857, ix, 34. 2 Dis. of Children, 1874, 363. 

3 Prager Vierteljahr., 1856, iv, 23. 4 Tiirck, p. 223. 

5 Herard, l'Union Med., July 14, 1859, quoted by Trousseau, Clin. Med., 
Syd. Soc. Trans., 2d ed., vol. ii, p. 407. 



A /'PEN D IX. 



351 



times), while the other cartilages were affected but 5 times. 
In 10 of the cases the cricoid and arytenoid were involved 
simultaneously. 

It is to be specially observed that probably a number of 
the cases which recovered were also really cases of peri- 
chondritis, of which the positive evidence was wanting. 




Fig. 4 — Perichondritis larynges following typhoid ; abscess opened from 
esophagus and seen from behind : a, b, Necrosed and partly destroyed cricoid 
cartilage ; between a and b the dark area indicates the point where the abscess 
communicated with the trachea ; it did not communicate with the esophagus ; 
c, crico-arytenoideus posticus muscle. (Tiirck, Krankh. des Kehlkopfes, page 
218, Fig. 80.) 



Thus, in 8 cases in which recovery followed tracheotomy, 
the patients spat up gangrenous or purulent matter, besides 
having other symptoms of cricoid necrosis ; but as the ex- 
pectoration of any pieces of necrosed cartilage was not posi- 
tively observed, I have not included them in my statistics 
of necrosis. Were they included, the result, and especially 
the result after tracheotomv, would be far more favorable. 



352 SURGERY OF TYPHOID FEVER. 

Whatever the origin of the necrosis, the cartilage is soon 
destroyed, either by molecular disintegration or is even 
broken in pieces. Sometimes it undergoes ossification ; at 
others, caseous degeneration. The articulations of the car- 
tilages are also often destroyed, especially those of the cri- 
coid, with the arytenoid or with the thyroid ; and thus 
again voice is impaired. The function of the muscles, 
especially those which open the glottis, is impaired or de- 
stroyed, from direct implication of the muscles or from 
destruction of their cartilaginous attachments, or of the 




Fig. 5. — Perichondritis after typhoid: Opposite a the edematous aryepi- 
glottidean folds are seen. Below the vocal chords the larynx was narrowed 
by thickening of the connective tissue. Opposite b a movable piece of the 
destroyed and broken cricoid, which has perforated the esophagus, is seen. 
(Riihle, Kehlkopfkrankh., page 178 and Plate I, Fig. 2.) 



articulation ; and thus the vocal chord of that side is immo- 
bilized, and altered voice and stenosis of the larynx follow. 
If an abscess form about the cricoid, it may not only burst 
into the larynx but also into the pharynx, and a fistulous 
opening be established by which food may enter the larynx 
and trachea. This, Dittrich 1 thinks, is the most frequent 
point of opening ; but I have only found it recorded in six 
instances, though such an abscess would have burst here 
in several other cases had life been prolonged. An addi- 
tional complication may follow also in the pharynx. The 



Prager Vierteljahr., 1850, iii, 117. 



APPENDIX. 353 

cricoid presses upon its posterior wall, both from swelling 
and from gravity, and this pressure, together with the foul 
purulent discharge, may cause an ulcer ; or, as in a case 
recorded by Armstrong, ' a retropharyngeal abscess. Hoff- 
mann ' 2 records another case of retropharyngeal abscess 
extending from the base of the skull to the diaphragm, 
laying bare the left subclavian artery. This, however, did 
not result from a laryngeal necrosis. 

The earliest symptom of grave laryngeal disease is usually 
an altered voice. I have only found it distinctly stated as 
unaltered in three cases. Generally it is hoarse, some- 
times higher, but usually lower, in tone, probably from 
involvement of the crico-thyroid muscle. Sometimes com- 
plete aphonia sets in. Stokes ;] has supposed the hoarse- 
ness and deafness both to be due to the muscular degenera- 
tion, to which I shall allude hereafter ; but it is more likely 
to be due here, at least, to edema and inflammatory swell- 
ing, and, at a later period, to the mechanical destruction 
of the parts involved. 

Soon after this hoarseness is observed the dyspnea sets in. 
This is paroxysmal, the attacks being generally at night. 
With each succeeding attack the severity increases, until 
life is destroyed ; but even the very first attack may be 
unexpected, sudden, and fatal. Especially does this seem 
to be the case in typhus and in supraglottic edema. 
Emmet and others have recorded a number of cases in 
which, even without the least previous dyspnea, on simply 
assuming the erect posture sudden suffocation came on, and 
life was only saved by instantaneous laryngotomy. The 
delay of " a few minutes " caused death in one case which 
otherwise would probably have recovered. Most frequently 
the dyspnea is inspiratory, but I can not find that this is of 
any decided diagnostic value. 

The expectoration, curiously enough, aids us but little ; 
in but few cases did it attract sufficient attention even to be 
named ; but if it be purulent or gangrenous, it should 
arouse instant attention. Pain and tenderness, though 
often masked by the mental condition, are generally pres- 
ent, especially in perichondritis. As we have the resisting 
vertebral column behind the cricoid, I would strongly urge 

1 Pract. Illustr. of Typhus Fever, 1819, 399. 

2 Op. ciL, p. 388. 3 On Fevers, Phila., 1876, p. 105. 

23 



354 SURGERY OF TYPHOID FEVER. 

that both by direct and lateral pressure on the cricoid, and 
also by sliding it sidewise, we may often elicit pain which 
might otherwise be overlooked. Lateral pressure will also 
often produce dyspnea, or aggravate it, especially if the 
cricoid be broken, or nearly broken, in two. Dysphagia 
is noted as present 21 times and absent 5 times, and is 
especially present in cricoid and arytenoid necrosis. Rarely 
is there any external swelling to attract attention, for I 
have only found it noted thrice. Nor can the pharynx be 
relied upon to warn us of impending evil, for in 16 cases in 
which its condition was observed, it was normal in 10 and 
inflamed in only 6. 

Most of the cases occurred before the days of the laryn- 
goscope, so that I have only 13 such examinations from 
which to draw any inferences, 7 of which are recorded 
by Tiirck. In several instances there was nothing what- 
ever abnormal down to the vocal chords ; and the swelling 
of a cricoid abscess on the posterior wall is not visible. But 
the usual facts observed were the fixation of at least one 
chord in the middle line, diminished mobility of the other, 
swelling of the ary-epiglottidean folds, stenosis of the 
larynx increased by lateral pressure, a depression of the 
mucous membrane in case of destruction of the arytenoid, 
and sometimes the opening of an abscess, usually near the 
processus vocalis. A few such positive facts with any 
additional positive symptoms should lead to an equally 
positive treatment. 

And first the mortality is so great that the treatment is 
of the greatest possible moment. Of 146 cases of all 
kinds of stenosis in which the result is recorded, 101 died 
and 45 recovered, a mortality of over 69 per cent., but not 
a surprising result when we add the laryngeal disease to 
the exhausting fever. But when we separate the cases 
operated upon from those in which no operation is named, 
or was certainly not done, the importance of the treatment 
becomes even more appreciable. Of the 76 cases not 
operated on, in which the result is stated, — and, be it ob- 
served, I have included in these the cases of mere scarifica- 
tion, — 17 recovered and 59 died, a mortality of over yy 
per cent. Of the 70 cases operated on by some form of 
bronchotomy, 28 recovered and 42 died, a mortality of 60 
per cent. And when it is remembered that in two of the 



APPENDIX. 355 

fatal cases the larynx was not opened, though tracheotomy 
was apparently performed ; and a third, in full recovery 
thirteen days after the operation, on the removal of the 
cannula was suddenly suffocated before it could be replaced ; 
and in another the cannula got displaced in front of the 
trachea ; that in many, if not in most, of the cases, the 
operation was deferred until the last possible — that is, the 
most unfavorable — moment ; that many cases that might 
have been rescued were plainly allowed to die from exhaus- 
tion, or even from positive suffocation, by timid doctors, in 
which the result could not have been worse had an opera- 
tion been performed, the question of operation would seem 
to be decided. 

Yet I would not be understood as an advocate of rash 
and indiscriminate bronchotomy. Its dangers are great, 
and not to be undervalued. The question, however, is often 
between a dangerous operation and a more dangerous 
refusal. In case the attack is sudden and severe, so that life 
is in immediate and positive peril, no question can arise as 
to the propriety of an operation, wanting which the patient 
perishes on the spot ; nor any question that crico-thyroid 
laryngotomy is the easiest, safest, speediest operation. 
Delay here means death. Of 14 such operations, 8, 01-57 
per cent., recovered, and in such cases as are recorded by 
Emmet and Anderson 1 no words can add force to the fact 
that after life was apparently extinct, laryngotomy and arti- 
ficial respiration saved five, the delay of a few minutes re- 
sulting fatally in the sixth case. A cut throat here is not 
over-dangerous, and the operation is so simple and may 
be so imperative that every medical man, as well as sur- 
geon, should stand ready to do it in case of impending 
death. 

But it is in the less suddenly threatening cases that judg- 
ments may differ, and here I hope to be able to assist in 
forming a decision. The moment, in a case of typhus or 
typhoid, that hoarseness, aphonia, dyspnea, or dysphagia 
sets in, the larynx should be examined with the utmost 
vigilance both from without and by the laryngoscope. If 
edema or ulceration be found, but the danger be not as yet 
severe, leeches, iodin, ice in rubber bags, or, possibly, a blis- 

1 Ten Lectures on Fever, London, 1861, 46. 



356 SURGERY OF TYPHOID FEVER. 

ter may be used externally, and astringents, nitrate of silver, 
etc., internally, together with proper general treatment. In 
1 8 19 Lisfranc proposed scarification and operated success- 
fully in six non-febrile cases, and in 1847 Buck revived the 
practice and devised an appropriate knife. The laryngo- 
scope has made such treatment far more certain, and it 
should first be tried in suitable cases. 

But, should these means fail ? Then an early rather 
than a late tracheotomy, for otherwise we add to the previ- 
ous enfeebling disease a prolonged battle for breath, with 
its ensuing pulmonary congestion and general exhaustion. 
Especially is this to be commended in the peculiarly fatal 
necrosis of the cartilages. Of 67 positive cases, 41 of 
which occurred in men and only 10 in women, all died but 
2, one with and one without an operation ; 22 w r ere oper- 
ated on, 45 were not. But, as before mentioned, 2 died 
from displacement of the cannula, at least one of which had 
practically recovered ; 8 cases of recovery after tracheot- 
omy are not included, since, though the presumption in 
favor of necrosis is very strong, yet the evidence is not 
positive. Were only these 8 included, and it is certainly 
fair to do so, it would stand 30 operations and 10 recov- 
eries, a mortality of 67 per cent., and 45 not operated and 
1 recovery, a mortality of nearly 98 per cent. 

Once, then, that perichondritis is established, death is 
almost unavoidable if no operation be done. If bronchot- 
omy be resorted to, the chances are greatly improved. 
Indeed, it is probable that if the dangers which surround 
such cases be recognized in the future, and a prompt attempt 
at relief be made, far more favorable results will be ob- 
tained. I would, therefore, join with Sestier in urging an 
immediate operation the moment that perichondritis is rec- 
ognized and serious dyspnea sets in, without waiting for 
repeated attacks to exhaust the slight store of strength, all 
of which will be needed during the subsequent separation 
of the necrosed cartilage, and the sloughing of the soft 
parts. 

In other cases than those of perichondritis such haste 
will not be necessary : yet if the respiratory murmur be 
progressively enfeebled ; if pulmonary congestion set in ; 
if the paroxysms of dyspnea increase in frequency and 
severity, especially if orthopnea arise ; if the local disease 



. / WEND IX. 357 

be extensive or rapidly increasing ; or if the genera] feeble- 
ness be so great that a little further interference with the 
respiration will destroy life ; then no time is to be lost. 
1 )oubt is certain death. 

What operation shall be performed ? If an instant 
operation be needful, crico-thyroid laryngotomy is the best ; 
if time allow, tracheotomy. But if the cricoid be involved, 
with Heck, 1 I would advise laryngo-tracheotomy, — i. e. t 
tracheotomy prolonged through the cricoid, — since it would 
allow readier access to the seat of the disease for the dis- 
charge of the pus, the removal of any loose piece of car- 
tilage, and the treatment of any ulcers or granulations. 
These I regard as greater advantages than the danger of 
possible collapse of the lateral halves of the cricoid, which 
is prevented in part by the cannula, and would not impede 
the respiration even if it occurred. Unless necessary, it is 
best not to operate during a paroxysm ; since the mechan- 
ical difficulties of the operation are then largely increased, 
and the danger of entrance of air into the veins is appar- 
ently much greater. In 36 operations for laryngeal angina, 
two such accidents occurred ; whereas, in 245 non-anginose 
cases, not a single similar accident arose (Sestier). 

Hemorrhage, as would be supposed from the condition of 
the blood, is sometimes a serious complication, both at the 
operation and subsequently, and caused death in three cases. 

A curious and unexpected complication arose in two 
cases reported by Mohr 2 and Laennec, 3 the knowledge 
of which should guard us against a similar error. The 
operation having been apparently achieved and the cannula 
inserted, respiration was not bettered nor did air pass 
through the cannula. In a few minutes the patients died 
suffocated. At the post-mortem it was found that the 
cannula had entered, not the larynx, but the abscess around 
the cricoid. In Mohr's case the vertebrae were felt through 
the incision, and a probe and the cannula moved freely about 
in what was naturally believed to be the trachea but proved 
to be the abscess cavity. 4 

1 Verhandl. Phys. Medic. Gesellsch., Wiirzburg, 1868, i, 27. 

2 Casper's Wochen., 1842, p. 192. Also in Dittrich, Prag. Yierteljahr. , 
1850, iii, p. 129. 3 Bayle, Nouveau Journ.. t. iv, p. 37. 

4 Green, Brit. Med. Jour., Dec. 17, 1870, p. 649, and Marsh, St. Barth. 
Hosp. Reports, iii, 368, report cases (not following fevers, however) in which 
the tube was inserted in the cellular tissue in front of the trachea. 



358 SURGERY OF TYPHOID FEVER. 

In three cases of edema the cannula was removed in six, 
eight, and nine days respectively. But after such serious 
loss of substance and extensive organic mischief as are in- 
volved in the cases of perichondritis, it is not a matter of 
wonder that the stenosis of the larynx is generally per- 
manent. In 17 cases of probable or actual perichondritis, 
the cannula was removed in one case after seven months, 
but in the other 16 cases, when last seen, the patients were 
still wearing them. Once, after seven years' use, a piece of 
the cannula wore away, broke off, and fell into the trachea, 
whence it was successfully removed by Albers. Busch, 
Russell, and others have attempted to dilate the stricture, 
both from above and below, but without any success. 1 

IV. Gangrene. 

The cases of gangrene may be divided into two classes : 
A, those from pressure ; and B, cases of spontaneous gan- 
grene. 

A. Those from pressure, or the ordinary bedsores, are not 
peculiar to the continued fevers, as is well known, but arise 
from any prolonged debilitating disease or accident. They 
are more common, therefore, in typhoid fever than in 
typhus, on account of its greater duration. But they not 
infrequently follow typhus, if it be prolonged by any com- 
plication. The only points in addition to the greater dan- 
ger of pyemia, to which I desire to call attention, are as 
follows : 

First, as pointed out by Nelaton, 2 Blandin, 3 and others, 
if they penetrate deeply they may destroy the ligaments 
uniting the sacrum and coccyx, and so penetrate into the 
spinal canal and set up meningitis, etc. This complication, 
I believe, arises much more frequently from bedsores, what- 
ever their cause, than is generally known. Recently I 
have had two instances : one arising from a bedsore follow- 
ing confinement, the specimen which I show you, and which 
I owe to the courtesy of Dr. Schell, my colleague at St. 

1 By the courtesy of Drs. Otis and Woodward, of the Army Medical 
Museum, the casts and specimens of Dr. Buck's case, p. 342, and of several 
cases of laryngeal stenosis, were shown. 

2 Path. Chir., Paris, 1844, i, 256, 257. 

3 Anat. Top., 2me ed., p. 437. See also Charcot, Mai. du Syst. Nerveux, 
2me ed., i, 89, 90. 



APPENDIX. 359 

Mary's Hospital; and the other in a boy who injured his 

knee and died some weeks after from tetanus induced prob- 
ably by this complication. I have found six cases of teta- 
nus recorded; four following typhoid and two typhus. 
Four of them were females. In one it was clearly caused 
by a bedsore. 1 Four of them died, but the two women 
who recovered had had menstrual irregularities, which 
probably caused the alleged tetanus. 2 

Secondly, large bedsores, as in two cases reported by 
Chenu in the Crimea, 15 may greatly hinder free motion of 
the legs and trunk by the extensive cicatrices. 

Thirdly, the treatment first proposed, I believe, by Brown- 
Sequard, of ice poultices for fifteen minutes, followed by hot 
flaxseed poultices for two to three hours, often stimulates 
the most indolent bedsores to heal with surprising rapidity. 
During and since the Civil War I have repeatedly and suc- 
cessfully tried this plan of treatment. 

Sometimes gangrene results from the slightest pressure, 
as in a case reported by Stokes, 4 in which there were 30 
such spots, two or three new ones appearing every morn- 
ing at points of such trifling pressure as where the mammae 
leaned on the arms, or one leg on another, and a black 
hand appearing where the face had rested on the hand. 
Strange to say, the woman recovered after a month's 
abdominal decubitus. For such cases Liebermeister recom- 
mends an almost continuous and complete bath, the body 
resting and reclining on sponges. 

B. But the cases of so-called spontaneous gangrene, 
though less frequent, are of far greater interest from a sur- 
gical point of view. They vary greatly in frequency. Thus, 
neither Flint nor Trousseau ever saw a case ; Nelaton does 
not name fever as a cause of gangrene ; Murchison, though 
he has seen a few, does not cite a single English post-mor- 
tem. Yet Estlander 5 reports 34 cases, and I have collected 
in all 113 cases. The frequency varies in proportion to 

1 Maclagan, Edinb. Med. Jour., 1867, 297. 

2 Delairiere (Jour, de Med. Chir. et Pharmae., xiii, 19) reports also a 
case of hydrophobia, which became ataxic, following a quotidian fever. The 
patient had been bitten by a healthy dog three months before. R. Reid 
(Pathol, and Treat, of Fever, Trans. Queen's Coll. Phys. Ireland, iii, 41) 
alludes to the similarity of hydrophobia and the excitable stage of fever. 

3 Rapport, pp. 520, 524. 4 On Fever, Phila., 1S76, p. 210. 
5 Archiv klin. Chir., 1870, 453. 



360 SURGERY OF TYPHOID FEVER. 

the severity of the case and of the epidemic, and espe- 
cially to the preceding conditions as to bodily nourishment, 
mental depression, and general mode of life. In former wars 
especially, from the time of Thucydides to that of Napoleon, 
fierce epidemics, especially of typhus, have deciminated 
armies and often displayed a most frightful tendency to 
gangrene. But of late, whether in civil or military prac- 
tice, if we may judge from the scanty gleanings I have 
been able to obtain from the journals and the experience in 
our own Civil War as well as in the late European wars, the 
condition of the sick has been so ameliorated that gangrene 
is happily a rare complication. 

The history of the extraordinary series of cases reported 
by Estlander well illustrates these predisposing causes. In 
Finland, a financial crisis and a series of bad harvests from 
1862 were followed in 1865—67 by sporadic cases of fever, 
mainly typhoid ; but from the thrifty habits of the people 
and governmental support, the epidemic was at first neither 
severe nor extensive. Then came the cold and rainy 
summer of 1867, followed by a very bad harvest. That 
winter typhus raged in almost every household, so that 
often the well were not numerous enough to nurse the sick. 
The death-rate rose from 2.74 per cent, to 7.69 per cent. 
Instead of an annual increase in the population of over 
15,000, it decreased in 1868, nearly 94,000 ; and this in a 
population of less than 2,000,000. Of 105 doctors, 30 
sickened and 8 died. Up to 1868 not a case of gangrene 
occurred, but in the first seven months of that year 28 cases 
occurred. Then came the bountiful harvest of 1868, and 
by August the epidemic had almost disappeared. Yet the 
lingering effects of the previous want were seen in six later 
cases of gangrene. But such an experience is altogether 
exceptional. From other writers I have rarely obtained 
more than two or three cases. 

Estlander's 34 cases were all, except one, from typhus ; 
but of the remaining 79 cases, 43 followed typhoid, 22 
typhus. The influence of age is not very marked, as is 
seen in the fact that of 76 cases, 8 occurred before fifteen, 
27 from fifteen to twenty-five, and 32 after twenty-five 
years of age. But sex, as usual, has a marked determin- 
ing influence. Of 81 cases, 56 were males and 25 females. 
This is the more curious when we consider that the 



APPENDIX. 361 

number of deaths in men, and therefore presumably of 
eases, does not hold at all the same relation. In [868, in 
Finland, 31,000 males and 28,000 females died ; yet of 31 
eases of gangrene of the legs, 25 were males, and only 6 
females. The site of the gangrene is very suggestive also. 
In 5 cases it was in the ears, 10 in the nose, 27 in the face, 
neck, and trunk, 5 in the arms, 7 in the genitals, and 72 in 
the legs; that is, of 126 localities, in yy it was in the ex- 
tremities, and in 22 more in other peripheral districts of 
the vascular system — ears, nose, and genitals. 

As far as the pathology of the cases is concerned, they 
may be divided into two classes : (1) Those with a discover- 
able clot and (2) those without such a clot. Murchison 
believes that all cases of spontaneous gangrene arise from 
arterial thrombosis, but the careful post-mortem examina- 
tions of Estlander and others show that, at least in the 
larger visible vessels, sometimes no such thrombus exists. 

1. Those with clot. The cause of such clots, as Hum- 
phrey 1 and others have shown, is not the condition of the 
blood-vessels. But seldom have I found it stated that the 
arterial walls were diseased, and when they were it was 
presumably a secondary process, the result and not the 
cause of the clot. Few, if any, pathologists will now 
attribute such results, with Bourgeois, 2 to a metastasis, 
especially when arising in convalescence, as these so fre- 
quently do. Gigon 3 has attributed them to chemical altera- 
tions • in the blood which give it an irritative character, 
and this, with friction at points of curvature, produces 
inflammation and coagulation. If so, a fair proportion of 
cases should be seen in the upper extremities, where the 
same irritating blood circulates and similar curves exist. 
How rare this is we have already seen. 

Although the precise factors in determining the throm- 
bosis in an}' individual case may be somewhat doubtful, as 
also why it is frequent in one epidemic and rare in another, 
apparently frequent in Germany and rare in Britain, and 
especially rare in the United States, yet three causes clearly 
exist which may vary inter se in producing the result : (1) 
The altered blood ; (2) the weakened heart ; and (3) the 

1 Brit. Med. Jour., 1859, p. 582. 

2 Arch. Gen., Aug., 1857, 149, and L' Union Med., 1861, xii, 80, 249. 

3 L'Union Med., 1S61, xi, 577, 611, and xii, 127. 



362 SURGERY OF TYPHOID FEVER. 

mechanical difficulties in carrying on the circulation, especi- 
ally in distant parts. 

That the blood is profoundly altered, and probably has an 
increased coagulability, is conceded. In some cases, even, 
air is found in the veins, as noted by Crisp 1 and Lebert. 2 
That every such change, besides its depressing effect upon 
the nutrition, and therefore upon the vitality of the tissues 
themselves, would interfere more or less with its circulation, 
and consequently predispose to thrombosis, is most prob- 
able. But when we look at the seat of the cases of gan- 
grene of both varieties which are under consideration, I 
think the conclusion is inevitable that the last two causes 
are the more immediately determining factors. 

The heart, as Stokes showed, is softened in its texture, 
and therefore weak. Hayem 3 has shown that myocar- 
ditis is extremely frequent, and not rarely involves the 
endocardium. From the sixth to the fourteenth day is 
its weakest period, and not only is the general force of the 
circulation diminished at this time, but, all the blood not 
being squeezed out of its cavity, clots may form in the 
heart, and then, or at a later period, when the heart regains 
somewhat of its force, be washed into the circulation and 
lodge as emboli. Such seems to have been the origin 
of the clot in a remarkable case related by Patry. 4 A 
decolorized adherent embolus was found high up in the left 
external carotid, on which a secondary thrombus had 
formed nearly down to the bifurcation of the primitive 
carotid. Pain appeared from the jaw to the temple on the 
twentieth day of typhoid ; two days later the ear was cold 
and violet, the artery pulseless, and the gangrene rapidly 
extended to the entire left side of the head and face, involv- 
ing even the bones. I have found, however, but eight 
other cases in which the embolic nature of the primary ob- 
struction was clear ; but often the want of a minute exam- 
ination of the clot renders the report useless, and sometimes, 
probably, the primary embolus is so overshadowed in size and 
importance by the secondary thrombus as to be overlooked. 

1 Dis. Blood-vessels, p. 18. 

2 Prag. Vierteljahr., 1858, i, 33. Moorehead, Trans. Med. and Phys. 
Soc, Bombay, 1843, P- 68, also reports a case. 

8 Lemons clin. sur les Manifest. Cardiaques de la Fievre Typhoide, 
1875, 49. 4 Archiv. Gen., 1863, i, 144. 



APPENDIX. 363 

The third factor, the mechanical difficulties of the distant 

circulation, combines almost inextricably with the weakened 
heart in producing the spontaneous coagula or thrombi. 
It is, nevertheless, clearly the principal factor in precipitat- 
ing the gangrene in the lower extremities. Not only, 
however, are the inferior parts of the body thus involved in 
gangrene, but the frequency of venous thrombi, and the 
resulting phlegmasia^ in the same region, is a strong argu- 
ment in the same direction. Houchut 1 found in 51 cases 
of non-puerperal venous coagula that 44 were situated in 
the pelvic, femoral, or tibial veins. I have memoranda of 
63 cases of venous coagula following the continued fevers 
in which the site is stated. Only two cases involved the 
upper extremity alone, and both were followed by gan- 
grene ; one involved both the arm and leg ; all the other 60 
cases were limited to the lower extremities. 2 Both forms 
of coagula — the arterial and the venous — form most fre- 
quently during or just after the period of greatest cardiac 
weakness — a weakness felt most at such distant points, as 
the legs. Of 18 arterial cases 12, and of 43 venous cases 
24, occurred in the second and third weeks of the fever. 
Moreover, the preceding circumstances — such as famine, in- 
dividual poverty, and the deprivations of war — are such as 
impair the nutrition and the circulation in the peripheral 
districts of the body. The coagulation also takes place at 
points mechanically favorable to slowing of the currents — 
e. £"., the bifurcation of arteries and the valves in the veins. 11 
In the veins, at least, as described by Humphrey, the clots 
are sometimes laminated, the outer layers of decolorized 
fibrin, and therefore the oldest, and the center, a bar- like 
recent coagulum of dark or black blood. 

Once that the obstruction exists in the artery, it extends 
by additional coagulation, so that the collateral circulation 
may be widely and rapidly cut off. The progress of the 
clot can often be watched from day to day by the pro- 
gressive annihilation of the pulse — first, for example, in the 
tibial, then in the popliteal, then in the femoral or higher — 

1 Gaz. Med. de Paris, 1845, P- 2 4 J - 

2 See a very interesting case which got well after a second attack of typhus 
thirty years later, Stokes on Fevers, Phila., 1876, p. 249 (republished in Med. 
News and Library). 

3 See a carefully reported case of Phlegmasia by Cole, Med. Times and 
Gaz., 1875, i. 5- 



364 SURGERY OF TYPHOID FEVER. 

and by the parallel progress of the gangrene. In cases of 
recovery this cessation of the pulsation and the hard tender 
cord in the course of the vessels are, of course, the only, 
but sufficient, proof of their occlusion. That gangrene 
follows so much more frequently in febrile thrombosis than 
after the traumatic thrombus which accompanies ligation 
is not surprising, in view of the condition of the blood, the 
general enfeeblement, and the more wide-spread arrest of 
the collateral circulation. Yet, on the other hand, pyemia, 
which has so much to favor it, especially in the cases of 
venous thrombi, is a rare sequel. Even when it does 
follow, it is in most cases apparently the secondary result 
from the septic influences arising from the gangrenous 
parts. 

The circulation in the artery being cut off, it is not 
strange that clots should follow in the veins ; but even 
where both are obstructed moist gangrene rarely follows. 
The foot especially generally mummifies. But this is not 
always the case. Occasionally the gangrene is moist from 
the beginning, from early obliteration of the vein, or, having 
begun as dry gangrene, — c. g. y of the foot from a popliteal 
clot,^suddenly both the femoral artery and vein may be 
obstructed, and a moist gangrene of leg or thigh be added. 
Gangrene from venous obstruction alone is very rare. 
It is more apt to follow in the arm than in the leg. 1 

Coagulation of the blood may also be caused occasionally, 
by direct mechanical causes in fevers, as in a case given by 
Jaesche, in which a swollen gland surrounded the common 
iliac artery at its bifurcation and caused a clot, probably by 
direct pressure or by induced arteritis. 

2. The second variety of spontaneous gangrene is that 
in which no clot apparently exists — certainly no such clot 
as is commonly designated either an embolus or a thrombus ; 
that is, a local clot of some size in an arterial trunk, which 
cuts off the circulation in the tissues supplied by its 
branches. But even in these cases I believe that the con- 
ditions affecting the circulation, already so fully considered, 
will more readily and rationally explain the causation of the 
gangrene than any specific action of the indefinite though 

1 Hueter (Virchow's Archiv, xvii, 48) records, however, a very interesting 
case of gangrene of the right leg following a spontaneous clot without assign- 
able cause, the vein wall being healthy. 



APPENDIX. 365 

undoubted poison of the fever. Coagulation I believe still 
to be the cause, but not in the larger trunks. Jt begins, 
rather, as a blood stasis in the capillar}- circulation. The 
parts in which the often extensive coagulation takes place 
are at once struck with gangrene, and, as the blockaded 
vessels themselves are all involved in the general destruction 
of the gangrenous tissues, all evidence of the nature of the 
lesion is thus destroyed. This form of gangrene occurs 
generally in the nose, ears, penis, perineum, labia, feet, and 
occasionally the fingers ; that is, in parts supplied by no one 
large vascular trunk, but by many smaller branches — not 
only in parts distant from the center, such as the feet, but in 
parts which lose their heat most readily by reason of their 
thinness and small size, and parts irritated, it may be, by 
local discharges. Very probably, also, it may be due to 
the fatty degeneration of the smaller arteries, as observed 
by Hoffmann, Zenker, and Ponfick. Raynaud 1 (and, fol- 
lowing him, Fischer and Estlander) ascribes it to a spastic 
ischemia, from contraction of the arterioles. The frequent 
bilateral or symmetrical character of this variety, to which 
Raynaud has called especial attention, would indicate at 
least the probability of some such central cause. Whether, 
if it exist, it be the direct result of irritation of the nerve- 
centers, as is seen in the other nervous phenomena of fever, 
or whether it be a reflex spasm caused by the circulation of 
deteriorated blood, similar to that to which Dr. George 
Johnson has attached so much importance in Bright's 
disease, we can at present only surmise. 

The symptoms of gangrene are marked and character- 
istic. Toward the end of the fever, especially in the third 
week, or early in convalescence, as weakness is giving place 
to strength, and the brightest hopes of speedy recovery are 
cherished, sudden, severe, and persistent pain is felt. Usually 
it is at the seat of the impending gangrene, though not 
uncommonly at the clot itself, radiating thence to the 
periphery. In the lower extremities it is often felt in the 
ball of the great toe or in the heel. It is followed by 
numbness, coldness, loss of sensation, and sometimes of 
motion, and in a short time discoloration and all the other 
usual evidences of gangrene appear. Sometimes, but not 

1 De l'Asphyxie locale et de la Gangrene Symmetrique des Extrem., Paris, 
1862. 



366 SURGERY OF TYPHOID FEVER. 

usually, these local symptoms precede the pain. If the 
distal vessels be examined, the pulsation will be found feeble 
or utterly extinguished, while higher up, at the seat of the 
obstruction, they will be changed into moderately firm but 
tender cords, in which we may sometimes differentiate the 
artery from the vein — an important point in prognosis. 
Week by week, sometimes day by day, the process of the 
coagulum may be traced upward by the abolition of the 
pulsation and by the upward march of the gangrene. If 
old cicatrices exist, they will be among the earliest parts 
to yield. Blebs may form in the early stages, but most 
frequently they will dry up, and the parts will mummify, 
although, as already indicated, moist gangrene may super- 
vene if a large clot form higher up, or if the veins are exten- 
sively obliterated, thus involving great masses of moist 
tissue, such as the thigh, in sudden ruin. 

Life may be rapidly destroyed, as, in a case recorded by 
Barker and Cheyne, 1 in two and one-half hours after gan- 
grene began in the nose ; but more commonly davs or weeks 
will elapse, during which nature, as usual, makes a powerful 
effort to rid herself of the dead parts by the establishment 
of a line of demarcation. On the establishment of this the 
pain often ceases. 

If recovery follow, the circulation is carried on by col- 
lateral branches, or, in very rare cases, the artery again be- 
comes partially pervious. 2 This last result Humphrey has 
shown to be not infrequent in veins, and Petres 3 has 
recently elucidated its mechanism through the extension 
and coalescence of the vasa vasorum. 

In the variety of gangrene without a thrombus, the 
symptoms will vary somewhat. It is not so uniformly in 
the lower extremity, and is much more frequently symmet- 
rical. If small in extent, pain is not apt to be a leading 
feature. The onset is often earlier, and from the nature of 
the case its progress is sharper, and its limits much more 
quickly defined, so that usually, within a few days, at least, 
the boundary of the gangrene is pronounced, since it does 
not progress with any gradually growing thrombus. For 
the same reason it less frequently returns in the stump after 

1 Account of the Fever lately Epidemic in Ireland, London, 1821, vol. i, 
p. 232. 2 Patry, Archiv. Gen., 1863, i, 136. 

3 Edinb. Jour., Aug., 1875, p. 175, from Le Progres Med. 



APPENDIX. 367 

an amputation. Its area, also, is usually much less than in 
those cases in which a thrombus exists, rarely extending in 
the leg beyond the foot or ankle ; and it rarely involves 
surrounding parts to a large extent if it occur in the nose, 
ear, genitals, etc. Sometimes, however, it may extend more 
widely, as in a case of typhus and starvation mentioned by 
Lyons, 1 in which the patient walked to the workhouse, and 
on baring his chest the whole of the right side was " a dark, 
olive-green, jelly-like, tremulous mass." The abdominal 
wall is sometimes similarly involved. The probably irreg- 
ular area in which the stasis of the blood will take place in 
this form also accounts for the great irregularity generally 
seen in the line of demarcation ; whereas, if a clot exists, it 
is apt to be fairly even. This sudden history is usually 
followed by a speedily decided issue. Death follows 
quickly, or reaction and recovery set in within a short time, 
instead of hanq;in<>- in the balance for months. 

The results of spontaneous gangrene vary much, according 
to its situation and extent. In the extremities, if life be 
saved, the result is usually an amputation, either by nature 
or by the surgeon. In the nose, it may perforate the septum 
or destroy the entire organ to a greater or less extent. 
During some civil, as well as military, epidemics of typhus, 
this seems to have been a favorite spot for its beginning, so 
that the disease was popularly known early in this century 
as the " Blue Nose," 2 and inspired terror whenever it 
appeared. In 1834, Mauthner says, it was an extremely 
common result, seen in all the military hospitals, and " all 
hope was gone as soon as this dreadful symptom was seen." 
Another not infrequent form is noma, or cancrum oris. 
This is especially frequent in children and in the army. 
Murchison speaks of it in the Crimea as frequent and 
invariably fatal ; Chenu, however, in his report does not 
name it. Its ravages are extremely extensive, often involv- 
ing even the bones. 

The ear, also, and the eyelids are sometimes destroyed. 

1 On Fever, p. 191. 

2 See Mauthner, Ueber das typhose Fieber mit Nasenbrand, Hufeland\s 
Jour., 1834, lxxviii, 46; Kraft Ueber Typhus Bellicus u. die blaue Nase, 
Hufeland's Jour. , 1815, xli, 81 ; Gutberlet, Die blaue Nase bei dem Typhus 
Bellicus, Hufeland's Jour., 1816, xlii, vi, 101 ; Wendelstadt, Die blaue 
Nase beim Typhus Bellicus, Hufeland's Tour., 1816, xliii, v, 131, and Barker 
and Cheyne, loc. cit. , i, 232. 



368 SURGERY OF TYPHOID FEVER. 

From each of these, singly, or all together, the most fright- 
ful deformities often follow, which require the utmost 
ingenuity in the plastic operations necessary to remedy 
them. In many cases the gangrene is local and subcu- 
taneous, producing necrobiotic masses of tissue, which are, 
I believe, often, if not generally, the cause of the abscesses 
so commonly seen in all parts of the body. Sometimes 
even the mediastina are opened, — the anterior from the chest 
wall, the posterior from the deep tissues of the neck 1 , — unless, 
by a timely surgical operation, the danger be averted. 

The male genitals are occasionally destroved to a greater 
or less extent. Except the organic destruction, no special 
result follows, except, possibly, hemorrhage, for one case is 
recorded of death from a hemorrhage of f^xxx from the 
scrotum. 2 

That the perineum and the female genitals are not more 
frequently the seat of gangrene is rather surprising, when 
we consider the neglected condition of many of the patients 
and the constant soiling of the parts, as a result of uncon- 
scious and unavoidable discharges, especially in females. 
The troubles of the female generative organs are either 
distinct external gangrene, or gangrenous ulcers in the 
vagina. I have found 9 cases, — 8 from typhoid and one 
from typhus, — all in young persons from seventeen to 
twenty-seven years of age, except one of thirty-four. In 
6 of the cases there was gangrene of the labia, extending 
sometimes to the perineum and the thigh. At least one 
case was followed by contraction of the vulva. 3 In 
another, reported by Gueneau de Mussey, 4 there was com- 
plete occlusion of the vagina and menstrual retention, 
necessitating puncture, with a fatal result. The ulcers are 
generally on the posterior wall of the vagina, and in three 
cases recto-vaginal fistulse have resulted. One is reported 
by Lebert 5 in which, when convalescent in the seventh 
week, chill, fever, and diarrhea set in, and four weeks later the 
fistula was discovered by injection. It was situated in front 
of the hymen, and was as large as a five-centime piece. A 

1 See Fraentzel, Berlin, klin. Wochen., 1874, xi, 97 ; Werner, Med. Cor- 
resp. Wiirttemb. Aerztl. Verein, Stuttgart, 1859, xxix, 76, and Hoffmann, loc. 
cit., p. 388. 2 Murchison, p. 194. 

3 Russell, Glasgow Med. Jour., 1864-65, xii, 165. 

4 Gaz. Hebdom., 1867, 652. 5 Anat. Path., ii, 307, and pi. cxv. 



APPENDIX. 369 

month later she died of pelvic peritonitis. A second is 
reported by Liebermeister. l It was caused by the slough- 
ing of a large piece of the recto-vaginal septum, in mass. 
The large fistula thus produced healed without operation. 
The third case has been under my own observation in St. 
Mary's Hospital for three years past, and is the only case 

1 have found of both recto- vaginal and vesico- vaginal 
fistulae. [For this case in full, see Case II, p. 80.] 

The perineum suffers mostly in males as 8 to 3, while in 

2 cases the sex is not stated. Typhoid was the cause in 
11, typhus in 2. Although not all cases of gangrene, 
they may be surgically grouped together, since all but one 
produced perineal fistulae. The exception 2 was a case fatal 
from a large abscess around the membranous urethra. 
Three fistulae were caused by necrosis of the pelvic bones 
or sacrum, and nine by gangrenous ulcers, which sloughed 
not only externally, but in five certainly communicated 
with the rectum, and probably did so in others. Except 
two cases of twenty-one and twenty-two years of age, they 
all occurred (when the age is stated) from thirty-nine to 
seventy-four years of age, later in life than most of the 
other sequels. They arose from the third to the seventh 
week, — that is, during distinct convalescence, — and to this 
is probably due the fact that 10 recovered and 2 died, one 
from the peri-urethral abscess, the other from hemorrhage 
upon sloughing into the rectum. 

The question of treatment of gangrene is, after all, the 
most important in a practical point of view, and is divided 
naturally into the preventive and remedial. The general 
supporting treatment of the disease is, of course, the most 
important preventive. Next, a careful and repeated exami- 
nation of the body, especially the parts most likely to be 
attacked. If gangrene is specifically threatened, stimula- 
tion of the circulation, both at the center and at the threat- 
ened spot, is imperative. To stimulate the center, alcohol 
in liberal doses is the best remedy, and two extremely in- 
structive cases are given by Stokes. 3 In one, "the surface 
was cold, and the pulse imperceptible. From the middle 
of the calf of each leg downward over both feet the sur- 

1 Ziemssen's Cyc, Amer. ed., vol. i, p. 184. 

2 De Change, Arch. Belg. de Med. Mil., 1861, xxviii, 126. 

3 On Fever, Phila., 1876, p. 205. 

24 



370 SURGERY OF TYPHOID FEVER. 

face was black, the skin hanging in loose wrinkles, giving 
an appearance as if the patient had on a pair of black 
socks." Sixteen ounces of brandy in the first eight hours 
saved his life. Digitalis might also possibly be used with 
advantage. The peripheral circulation must be stimulated 
by such means as will assist the threatened circulation by 
inducing alternate dilatation and contraction of the arteri- 
oles. Permanently wrapping up the part in cotton, and 
other similar means, will but assist permanent vascular 
dilatation and stasis. The alternation of the two is the 
condition of health, and its artificial production will tend 
to restore healthful reaction. 

Chapman's ice- and hot-water bags to the spine, alternate 
heat and cold directly to the parts, with proper friction and 
stimulating liniments, at once commend themselves to us. 
The constant current battery also may prove an extremely 
useful aid, since it dilates the deep as well as the superficial 
vessels, and will aid the collateral circulation. 

But suppose gangrene actually occurs, what then ? Est- 
lander gives most judicious counsel here. W emust re- 
member that good results follow both to life and limb with- 
out operation, especially if the gangrene be limited and the 
patient not too exhausted. We must not, therefore, be 
rash in our interference. If amputation has to be done, 
the question as to where it should be done depends on the 
probable extent of the gangrene ; as to when, on the line 
of demarcation. In the non-thrombotic cases, as the line 
of demarcation is usually established within two or three 
weeks, and the disease is not then likely to be progressive, 
the amputation maybe done but little above or even through 
it. It is, therefore, usually best to wait for its formation. 
In the thrombotic cases, the clot and the gangrene are apt 
to be progressive. Until the line of demarcation forms, 
therefore, it is impossible to say precisely where the disease 
will stop. Yet we can gain some idea of the probabilities 
of the case from past experience. 

If the clot extend no further than the popliteal, the limb 
may escape gangrene altogether, and if it follow, I have 
found it limited in 9 cases — to the foot 4 times and to 'the 
upper calf in 5 ; if the clot extend into the femoral, I find 
the gangrene extended to the upper calf in 6 and to the 
thigh in 4 ; if the clot extend above Poupart's ligament, I 



APPENDIX. 371 

find in 10 cases it was limited to the foot in 1, the calf in 
3, and extended above the knee in 6. The results of am- 
putation are good, giving 21 recoveries to 21 deaths, but 
the recoveries are largely after amputations in the foot. 
Before demarcation was established, 5 out of 8 died ; after 
demarcation, 12 out of 22 : a mortality, respectively, of 63 
and 55 per cent. As a rule, therefore, wait for the line of 
demarcation, but amputate soon after its appearance ; but 
if danger of septic poisoning or of speedy exhaustion 
should appear, amputate at once, at or above the probable 
limitation of the disease, which, if the femoral be free, will 
not be, in the majority of cases, above the tubercle of the 
tibia ; but if the femoral be involved, amputation would 
probably be more dangerous than the expectant treatment. 
As dead parts slough, they should be removed to prevent 
septic poisoning. Fortunately, there is but little danger of 
hemorrhage, either primary or secondary, in the throm- 
botic cases, since the arteries are all plugged securely. 

Of course, the ordinary treatment of the gangrenous 
ulcers and abscesses, especially of the perineum and geni- 
tals, should be pursued, but I would particularly urge the 
importance of free incision, especially in abscesses in the 
vicinity of the anus, and the use of detergent and stimulat- 
ing washes in the vagina in case of sloughing of the 
labia, in order to prevent in both cases the establishment of 
fistulas. 

V. Hem ATOM ATA. 

The muscular system suffers, in typhus and typhoid 
fevers, in common with almost every other tissue of the 
body, undergoing a peculiar form of degeneration, resulting 
sometimes in rupture and the formation of hematomata. 
These, although not so strictly surgical as some of the 
other diseases noted, yet, as their proper surgical treatment 
is so important, I shall notice briefly. 

Apparently, the first published case was observed by 
that shrewd surgeon Velpeau, 1 in 1819, in the post-mortem 
examination of a soldier at Tunis. " Rupture of the mus- 
cles of the belly," says he, "is not surprising. The organs 
become so fragile in advanced stages of putrid fever that 
their rupture is a phenomenon which is easily conceived 

1 Diet, en trente Vol. Art. l'Abdomerj, Rupture de. 



372 SURGERY OF TYPHOID FEVER. 

when the patient in his delirium moves so irregularly." In 
1844 Rokitansky noted their relation to typhoid. Virchow 
studied them also in 1857. 1 In 1864, however, Zenker 2 
first studied the subject thoroughly. Since then, but espe- 
cially within the last five years, they have been frequently 
observed or studied, mostly, however, from a pathological 
standpoint. 

The muscular changes to be described are so frequent as 
to be almost an essential part, at least, of typhoid. Yet 
they are not peculiar to these fevers. They are said to 
have been met with in phthisis, scurvy, scarlet fever, cholera, 
pneumonia, dysentery, measles, tetanus, B right's disease, 
cerebro-spinal meningitis, muscular traumatism, and I have 
seen a similar change in the muscles of the abdomen in 
cases of large ovarian tumors. 

There are two independent forms : (1) Agranular degen- 
eration of the muscular fibers, which is least frequent ; and 
(2) a waxy change, which is by far the commonest. Under 
the microscope the muscular tissue presents a glassy, trans- 
lucent, slightly opalescent, shiny appearance, the fibers being 
swollen to even double their usual size and changed to fragile 
cylinders. Sometimes the muscular tissue resembles even 
the flesh of fish. The nature of the change is as yet greatly 
disputed. Erb, 3 Bernheim, 4 and others attribute it simply 
to post-mortem imbibition; Hayem, 5 to proliferation of 
the tunica intima, which, with granulo-fatty change in the 
arterial walls, produces an obstructive arteritis ; Zenker 
ascribes the degeneration to the disturbance of a center 
which regulates the nutrition of the muscles; Waldeyer, 6 
Hoffman, 7 Ranvier, and Weihl 8 believe that it is a coagu- 
lation of the myosin ; and Liebermeister that it is due to 
the long-continued high temperature. Whatever the cause, 
the muscles become extremely fragile, and when they 
are called into play by the distention from meteorism, by 

1 Wurzburg, Verhandl., vii, and Virchow's Archiv, iv. 

2 Ueber die Verand. der willkiirl. Muskeln im Typhus Abdom., Leipzig, 
1864. 3 Virchow's Archiv, 1868, xliii, 108. 

4 Gaz. Med. de Strasb., 1870, No. 7. 

5 Gaz. Med. de Paris, 1866, 698. 

6 Centralbl. med. Wissensch., 1865, 97, and Virchow's Archiv, 1865, 
xxxiv, 470. 7 Virchow's Archiv, 1867, xl, 505. 

8 Virchow's Archiv, 1874, lxi, 253. 



APPENDIX. 171 

the efforts at coughing and other violent respirator}- acts, 
by defecation, rising in bed, the movements of the legs, etc., 
they rupture with the greatest ease. Spasm or direct vio- 
lence does not seem to have been noticed in any case. The 
arteries, which have also undergone an analogous change, 
are involved in this rupture, and muscular hemorrhages 
result. These assume three forms, according to their size 
and mechanical limitation: (i) Ecchymoses ; (2) diffuse 
infiltration into the muscular tissue, soaking it with blood ; 
or (3) distinct hematomata, the last being the most impor- 
tant and probably the most frequent. The effused clot, at 
first hard, well defined, and sharply limited, gradually 
softens, and not infrequently suppurates, thus producing 
serious abscesses which, unless opened, may even burst into 
the peritoneal cavity. 1 Meanwhile the swollen muscular 
fibers gradually undergo reabsorption, until finally they 
disappear entirely, and a new formation of cells takes place 
in the perimysium, which, according to Hoffmann, first 
become spindle-shaped, then coalesce endwise with one 
another, and gradually assume the appearance of striated 
muscular fiber. Complete repair is then effected. The 
resemblance of these spindle-shaped cells, which are nas- 
cent muscular fibers, to the muscular fiber-cells is most 
striking, and seems to form a link connecting the two forms 
of muscular tissue, the striated and non-striated, such as I 
have long taught to be probable. 

Almost all of the muscles may be thus invaded, but the 
favorite seats both for the degeneration and the hemato- 
mata are in the recti abdominis and the adductors of the 
thigh, then in the pectorals, and, as Hoffmann has noticed 
in 16 cases out of 22, in the diaphragm. The influence of 
the phrenic lesion in enfeebling the respiration is, perhaps, 
more serious than has been recognized. Zenker gives the 
adductors the first place, and Hoffmann reports the adduc- 
tors involved in the degenerative changes in 75 out of 107, 
the recti in 87 out of 127. While this may be true of the 
degenerative process, yet the hematomata are certainly 
most frequent in the recti. Of 60 positions in cases I have 
collected from every side, they were in the recti in 27, and 

1 Wenzel Gruber, in Jacops, Etude clinique sur les Absces. muse, qui 
surviennent pendant la Convalesc. de la Fievre Typhoide, These de Paris, 
1873, P- 42. 



374 SURGERY OF TYPHOID FEVER. 

the " abdominal muscles" in 9, in the adductors but 5 
times, and the upper extremities but twice. 1 If in the 
adductors, they may burrow so as even to strip off the 
periosteum from the bone. Hematomata are even found 
n the interventricular septum of the heart itself. 

Stokes suggests that febrile deafness and hoarseness may 
result from a similar degeneration of the muscles of the 
ear and the larynx. There are no post-mortem examina- 
tions on which to found such a hypothesis, and the fact 
that hoarseness and deafness are so often not seen, and 
that, as I have shown, 2 other and sufficient causes are 
found, at least in the larynx, render the idea scarcely tenable. 

Typhoid was the preceding fever in 44 out of 46 cases, 
but the severity of the fever seems to have but little in- 
fluence. Nineteen out of 25 cases occurred from fifteen 
to twenty-five years of age, and 22 were males as against 
8 females. They rarely appear before the third week, 
since the muscular fragility is then at its height. Of 23 
cases I find 19 arose in the third, fourth, and fifth weeks of 
the fever. Regeneration of the muscles usually begins in 
the third or fourth week, and is accomplished by the 
seventh, after which time they do not appear. Their 
period of development is, therefore, quite sharply defined 
by the anatomical history. 

As in dislocation of the hip-joint, the symptoms are often 
nil. Indeed, of 47 cases, I find 10 were wholly unsuspected 
until revealed at the post-mortem. The position of the 
tumor accounts in part for this. Both in the thigh and 
in the abdominal wall they are almost always in the 
posterior part of the muscle — a position due, probably, to 
the effect of gravity in the recumbent posture. Often, 
indeed, they are so deep as to extend to the pelvic and iliac 
muscles, and, in two cases, under the serous coat of the 
bladder. Hence there is usually little or no discoloration 
of the skin, though Foucault 3 reports a case with ecchy- 
mosis in the hypogastrium, extending later to the scrotum, 
thighs, and buttocks. Swelling is only reported 1 3 times, 
and fluctuation but 10 times. Suppuration and softening 
are but rarely attended with any special fever. Pain is 

1 In the recti they are, I believe, invariably below the navel, possibly on 
account of the absence of the support derived from the linse transversa. 

2 Ante, p. 353. 3 Bull. Soc. Anat., 1869, 498. 



APPENDIX. 375 

mentioned in 14 cases. Flexion of the legs to relax the 

abdominal wall, which we would suppose to be frequent, is 
named but once. The size of these blood tumors varies 
from that of a bean to that of an orange. If small, they 
may be obscured by meteorism ; the symptoms then being 
so indecisive, as in many of these surgical sequels, the 
necessity for frequent and rigid physical examinations is at 
once apparent. If a sudden and fixed pain exist in the 
recti below the navel, or even if movements be only hin- 
dered or uneasy and painful, a close examination should be 
made, and if a tumor or only hardness be found, it should 
be carefully scrutinized from day to day, especially for the 
pasty feel and other signs of edema and of fluctuation. The 
differential diagnosis is not usually very difficult. The 
most likely error, if in the rectus, is that of mistaking it for 
a distended bladder, but the catheter will at once unmask 
this error. If in the right iliac region, it may be mistaken 
for perityphlitis ; or in the adductors, for a simple abscess ; 
but as in point of practice the treatment of all three 
would be more or less similar, the error is of less moment 
than might be supposed. From aneurysm, an abdominal 
tumor, and peritonitis, the differential diagnosis is suffi- 
ciently easy. 

The treatment is important, especially when we consider 
the results. Of 13 cases opened by incision, only 2 died ; 
of 34 in which there is no mention of an operation, all died. 
If small, they will either be overlooked until the post- 
mortem reveals their existence, or, if recovery takes place, 
absorption of the clot and regeneration of the muscle will 
follow, independent of treatment. If large, every possible 
effort should be made by poultices, etc., to bring about 
early softening, and as soon as softened they should be 
opened. That the aspirator may be of service is probable, 
but as vet it is, I believe, untried. 



VI. Parotitis. 

Parotitis is occasionally an exceedingly important surgical 
complication, whose onset is always to be dreaded, lest it 
bring in other evils worse than itself. Murchison believes 
with Graves that the inflammation begins in the areolar 
tissue between the lobules of the gland itself, but Hoffmann 



37^ SURGERY OF TYPHOID FEVER. 

has unquestionably shown that, at least in typhoid, the 
pancreas and all the salivary glands are in a state of rapid 
cell-proliferation in nearly every case, and that parotitis 
proper is merely "an exaggeration of the changes that 
usually take place in this gland during typhoid fever, and 
bears the same relation to these changes that ulceration 
and perforation of the intestine do to the infiltration of the 
intestinal follicles." This exaggeration he believes to be 
due to the dense parotid fascia which compresses the gland. 
But this is not the only role this dense investing fascia 
plays. The compression of the swollen tissues not rarely 
produces gangrene, so that the entire gland may slough out 
in great masses like tow. In a case related to me by Dr. 
Grove, it involved both glands and proceeded so far that 
the fingers could almost meet behind the pharynx. The 
compression also is very favorable to thrombosis, which 
may extend to the brain by the diploic veins or even to the 
internal jugular itself. Necrosis and septicemia not rarely 
follow in its track. In two cases I have found facial palsy, 
from involvement of the seventh nerve. Facial deformity 
and ankylosis of the jaw are sometimes seen. In none 
does hemorrhage from the carotid appear to have followed. 
The death-rate is largely increased in such cases, since 
of 352 cases, 125 died and 227 recovered; a mortality of 
nearly one-third. The sex is named in only 19 cases, of 
which 14 were males. Contrary to the fact in other com- 
plications, except in perineal fistulse, this disease is most 
common after thirty. Of 211 cases, the average age, 
according to Murchison, was thirty-one and a half. It is 
certainly very rare in children, for I have found but 2 cases 
under fifteen. Typhus was the preceding fever in 352 
cases, and typhoid in only 26. Most cases do not go on 
to suppuration, for of 101, I find 40 suppurated and 64 did 
not. The abscesses generally discharge by one or often 
by several openings, the external meatus being frequently 
one of them. As Nelaton has pointed out, even where it 
has thus opened, if we would avoid burrowing and other 
subsequent troubles, we must open it still more freely, in 
order to divide the parotid fascia. 



APPENDIX. 377 



Conclusions. 

If now, by way of review, we cast our eyes back over 
the general results of all the complications and sequels we 
have studied, we may arrive at some useful and important 
conclusions. 1 

1. Typhoid, probably from its usually longer duration, 
is by far the more prolific source of such surgical troubles 
except parotitis, especially when we consider that many 
cases tabulated as typhus are really typhoid. Of 433 
cases, typhoid was the preceding fever in 252, typhus in 
1 19, and other forms of continued fever in 62. 

2. The surgical troubles to be apprehended in typhus 
are mainly restricted to gangrene and laryngeal stenosis, 
103 out of the 1 19 cases being due to these two classes of 
disease, while typhoid bears in its train any and all of the 
forms of disease described. 

3. The age is about the usual age of greatest frequence 
of these fevers. 2 From fifteen to twenty-five years is by 
far the most frequent decade, counting 133 cases against 
129 at all other periods of life. One singular exception is 
to be made — viz., the articular troubles, and especially dis- 
location of the hip, 21 out of 23 cases being under twenty 
years of age, of which 15 were in children under fifteen, 
in striking analogy to the frequency of coxalgiain children. 

4. Sex is an unexpected and important factor in the pre- 
disposition to febrile surgical troubles. Of 303 cases in 
which the sex is named, 218 are males and 85 are females, 
or over 2^ to 1. What is the normal proportion of the 
sexes in fever it is difficult to determine. In nearly 6000 
cases of typhoid, Murchison gives the proportions as pre- 
cisely equal, and in over 18,000 cases of typhus the females 
were in a decided majority (8871-9267). Estlander's 
figures would give us a slight preponderance of males, 
while Liebermeister, in over 2000 cases of typhoid, gives 
1300 males and 750 females. 

1 In this summary I have not included the cases of parotitis in the figures. 

2 Liebermeister gives the ages in typhoid as follows : fifteen to thirty, 
1310 ; thirty to seventy-one, 394 ; total, 1704. None under fifteen were ad- 
mitted. In typhus, fifteen to thirty, 39 per cent. 

Murchison gives in typhoid : fifteen to twenty-five, 2752 ; all other ages, 
3159 ; total, 591 1 ; and in typhus, fifteen to twenty-five. 5332 ; all other ages, 
12,806; total, 18,138. 



37^ SURGERY OF TYPHOID FEVER. 

Unfortunately, I omitted to tabulate the number of cases 
arising in military practice, which I am sure is not inconsid- 
erable ; but while this will account to some extent for the 
predominance of males, it could not be adduced in the 
cases of arthritis and dislocation, since most of the patients 
were children, yet the males were in the preponderance. 

5. The period of development is not the initial period of 
the fever, but first, from its height to its close — that is, the 
complications, especially gangrene and stenosis of the 
larynx ; and, secondly and most frequently, during conva- 
lescence — that is, the sequels. Of 240 cases, only 1 2 arose 
in the first week, 38 in the second, and 48 in the third, a 
total of 98. If we may assume that convalescence, on the 
average, begins at the end of the third week, then 142 
occurred during convalescence, when health is apparently 
in the near future. 

6. The lower half of the body is the especial seat of 
such surgical troubles. With the exception, of course, of 
the laryngeal cases and parotitis, of 307 cases 216 occurred 
in the pelvic region and legs, as against 91 in all other 
parts of the body. Moreover, the diseases attacking the 
upper half of the body are limited almost entirely to local 
gangrenes and caries and necrosis, and they are usually far 
less severe in type and more limited in extent than those in 
the lower half. Here whole limbs are blighted by gangrene ; 
here occur most of the dislocations, the hematomata, the 
fistulae ; here the severest necroses and largest abscesses, 
and were we to add the long catalogue of bedsores and 
phlegmasia^, the preponderance of the lower half of the 
body in importance would be still further increased. 

7. The diagnosis is, in general, moderately easy. The 
danger is not that difficulty of diagnosis may obscure the 
case, but that the diseases may be entirely overlooked. 
They occur most frequently in parts of the body covered 
by the bedclothes ; parts which require time and trouble to 
expose and examine in the routine of an ordinary visit. 
Moreover, the patient is frequently so apathetic and insen- 
sible to pain that he does not complain, or, if he do so, it 
is ascribed to the ordinary pains so frequent in the belly 
and legs in such fevers, or else to delirium itself. 

Hence the most important hint I can give in the diag- 
nosis — and where, indeed, does the same rule not hold good ? 



APPENDIX. 379 

— is that time and trouble must be taken, and that no 
patient suffering from a continued fever, and especially from 
typhoid, should escape frequent, minute, complete physical 
examinations, in which every part of the body from head 
to foot should be questioned. Especially should the physi- 
cal condition of the larynx, the belly, the legs, and the 
toes, and in children the hip-joint, be exactly ascertained. 
This should be done at least every second day, and that, 
too, not only in severe, but in mild cases, and not only 
during the fever, but especially in early convalescence, for 
it is in just such mild and convalescent cases that the wari- 
ness of the doctor is the patient's surest reliance. Particu- 
larly should attention be paid to hoarseness, or even to the 
slightest change in the voice, and the larynx be examined 
at once with the greatest care, from day to day, by the eye, 
the finger, and the laryngoscope, lest sudden edema or the 
more insidious and more fatal necrosis of the cartilages be 
impending. The eye should seize upon any hindered 
movements, even without discomfort, and no complaint of 
pain should fall upon a deaf ear, especially if it be in the 
throat, the belly wall, the buttock, the hip-joint, the legs, 
or the toes. True, it may mean nothing. It may be the 
vagary of a wandering mind. But it may also be, as we 
have seen, the herald of the gravest dangers, whose attack 
may be entirely repelled or their force broken by heeding 
this timely warning. 

8. The prognosis is naturally unfavorable, yet not to the 
extent we would suppose from the addition or sequence of 
such serious diseases. Of 383 cases in which the result is 
named, 220 died and 163 recovered, a mortality of ^7% 
per cent. 

9. Still more clearly, I think, after such a review, do we 
see the powerful influence of mechanical causes as the 
proximate factors in the production of such troubles, work- 
ing in conjunction with the profoundly vitiated blood. 
With the exception, perhaps, of the almost constant mus- 
cular degeneration, and its not infrequent subsequent hema- 
tomata, these surgical results are not usually primary but 
secondary processes ; not dependent directly on the fever 
poison, but its indirect and often distant results ; not con- 
stantly seen, but incidental, indeed, often rare ; not parts of 
the fever, but its complications and sequels. 



380 SURGERY OF TYPHOID FEVER. 

Pathologically, all these results may be grouped into two 
categories — viz.: (i) Those in which a clot exists; (2) 
those without any clot. 

1. Those in which emboli of cardiac origin or, more 
frequently, local thrombi exist are, unquestionably, most of 
the cases of extensive gangrene and phlegmasia. In many 
other cases in which such a clot is at present unsuspected, 
I believe that more careful examination will reveal its pres- 
ence in the smaller vessels, and prove that, if venous, it may 
be a cause of edema glottidis, and, if arterial, of the local 
necrobiotic processes which result in necrosis of the bones, 
and probably of the cartilages of the larynx, and gangrene 
of the soft parts, with its abscesses, fistulae, etc. 

2. Those in which no clot exists, and yet edema glottidis, 
dropsy, and dislocation of the hip, gangrene, ulcers, necro- 
ses, perichondritis, and other similar troubles occur. These 
are especially often ascribed to the fever poison itself, acting 
locally, and producing, for instance, the so-called laryngo- 
typhus, the abscesses and ulcers in the skin and subcuta- 
neous tissues, etc., which are regarded as specific. While 
not denying this view outright, and especially in some 
cases, I feel still more strongly disposed to look upon them 
as allied disorders, the immediate results, as in the case of 
the pneumonia of fevers, of mechanical conditions, which 
produce a local stasis of the blood, followed by edema, 
low forms of inflammation, or gangrene. True, these 
results of fever are most frequent in severe cases and severe 
epidemics, in which the poison would be the most virulent, 
but it must also be remembered that such epidemics and 
such cases are themselves, as a rule, the result of excep- 
tionally depressing pre-existing causes, such as famine and 
war, want and sorrow. Even simple inanition alone will 
produce identical results in many cases. 

But it is especially when we consider the position of the 
troubles that this mechanical factor is apparent. Their 
posterior position, as is seen in the laryngeal ulcers, the 
perichondritis, the vaginal ulcers, the fistulae, and in the 
hematomata the posterior surface of the. recti and adductors, 
is most significanl. Likewise is the fact that all such com- 
plications, as we have seen, are especially frequent in 
the lower extremities ; that is, in parts mechanically un- 



APPENDIX. 381 

favorable to a ready return of the blood, and eminently 
favorable, if not to thrombosis, at least to stasis. 

10. The treatment must be bold, but not rash ; conser- 
vative, but not timid. 

Note. — After the portion on Diseases of the Joints was stereotyped I 
received a letter from Dr. V. P. Cibney, of the Hospital for Ruptured and 
Crippled, New York City, giving the results in 860 cases of disease of the 
joints. The following is the only case which followed any continued fever, 
and it is not tabulated with the others: 

" William H , age twelve, presented himself at the outdoor department 

of the Hospital for Ruptured and Crippled, May 2, 1876. I lis general 
condition was good. The right hip was ankylosed, with the thigh abducted, 
semiflexed, and rotated inward, the trochanter carried upward, anil he 
pelvis tilted to the right side. There was apparent shortening of the limb, 
but the real shortening was not ascertained. The thigh was atrophied three 
inches. Immense cicatrices of bedsores were found, one over each posterior 
superior spine of the ilium, one over the right natis, and one over each 
trochanter major, that over the right being the deeper, and covered by a scab 
1^ by \]/ 2 inches. 

"Prior to October, 1875, he was in perfect health, but was taken that 
month with typhoid fever, and lay very ill for six weeks, during which illness 
the bedsores formed, and during convalescence the deformity at the hip was 
observed. This history I obtained from the mother, who was very intelligent. 
At the time I saw him the disease was practically arrested." 



INDEX 



A. 

Abscess, 147. 

abdominal, 156. 

of abdominal wall, 167. 

" bouton de chemise," 135. 

of brain, 169, 175, 322. 

ileo-cecal, 156. 

ischiorectal, 160. 

of mesenteric glands, 162. 

of ovary, 282. 

perinephric, 15 1, 152. 

psoas, 153. 

renal, 152. 

subdiaphragmatic, 163. 
Accommodation, paresis of, 312. 
Amblyopia, 319. 
Anthrax, 294. 

Anus, gangrene near, 83, 369. 
Appendicitis, 221, 231. 
Appendix vermiformis, 156, 330. 
Arthritis, monarticular, 95, 335. 

polyarticular, 94, 335. 

rheumatic, 91, 335. 

septic, 92. 

B. 

Bacilli of typhoid in the arteries and 
veins, 24, 60. 
blood, 23, 58. 
bones, 26. 
brain, 27. 

connective tissue, 25. 
fetus, 32. 
gall-bladder and bile, 

heart, 24, 29, 59. 
joints, 26, 97. 



Bacilli of typhoid in the kidney, 

3*- 

liver, 29. 
lungs, 29. 

mesenteric glands, 31. 
muscles, 25. 
orbit, 28. 
otitis media, 28. 
ovary, 32. 
parotid gland, 28. 
peritoneum, 29. 
perivascular tissues, 63. 
placenta, 32. 
pleura, 29. 
skin, 25. 
spleen, 30. 
synovial sheaths, 26. 
testicle, 32. 
thrombi, 24, 62. 
thyroid gland, 28. 
urine, 32. 
mixed infections of, 33, 289. 
mixed infections of, with sta- 
phylococci and streptococci, 
114. 
mixed with other special bac- 
teria, 289. 
pure cultures of, 37. 
pyogenic faculty of, 40. 
viability of, inside the human 

body, 19. 
viability of, outside the human 
body, 19. 
Bacillus, colon, differentiation from 

the typhoid bacillus, 39. 
Bones, central necrosis of, 135, 343. 
injury of, as a cause of infection, 1 22. 



333 



3§4 



INDEX. 



Bones, late infection of, 117. 

multiple lesions of, 1 19. 

muscular strain as a cause of perios- 
titis, 123, 343. 

oscillation in disease of, 143. 

typhoid affections of, 109, 322, 340. 

variety of disease in, 127. 
Brain, abscess of, 169, 175, 322. 

typhoid lesions of, 169, 322. 

C. 

Cancrum oris, 85. 

Cartilages of larynx, necrosis of, 149, 

347- 
Cerebral complications, 169, 322. 
Choroid, typhoid affections of, 303. 
Ciliary body, typhoid affections of, 

303- 
Conclusions, 314, 377. 
Conjunctiva, typhoid affections of, 

299. 
Cornea, typhoid affections of, 299. 



Death, sudden, after venous throm- 
bosis, 69. 
Dislocation of hip-joint, 96, 336. 



Ear, typhoid disease of, 181. 
Embolism, arterial, of cardiac origin, 
64, 362. 
of central artery of retina, 311. 
Epididymitis, 279. 
Erysipelas, 289. 
Esophagus, stricture of, 202. 
Eye, typhoid affections of, 296. 



F. 

FMstula, fecal, after typhoid, 157. 
perineal, 84, 369. 
recto-vaginal, 79, 369. 
vesico-vaginal, 79, 369. 



Gall-bladder, perforation of, 262. 

typhoid affections of, 248, 325. 
Gall-stones, typhoid bacilli in, 253. 
Gangrene, 52, 358. 

of cheeks, 86, 367. 

of female genitals, 79, 368. 

of male genitals, 78, 368. 

pathology of, 63, 361. 

of perineum and anus, 83, 369, 

symptoms of, 71, 365. 

treatment of, §7, 369. 
Genitals, gangrene of, male, 78, 368. 

female, 79, 368. 
Glossitis, 211. 
Gonorrhea, typhoidal, 278. 



H. 

Heart, typhoid affections of, 200. 
Hematemesis, 208. 
Hematocele, periuterine, 287. 
Hematomata, 166, 371. 
Hemianopsia, 313. 
Hemorrhage from the bowels, 209. 

from the stomach, 208. 

intra-ocular, 312. 

orbital, 312. 

retinal, 310. 
Hip-joint, dislocation of, 96, 336. 

I. 

Infections, specific mixed, 289. 
Intestine, perforation of, 212, 319. 
Intracranial veins, thrombosis of, 

176. 
Intubation, 197. 
Iris, typhoid affections of, 303. 



Joints, typhoid affections of, 91, 335. 



K. 

Kidney, typhoid disease of, 151, 152. 






INDEX. 



385 



Laryngoscopy examination, 195, 354. 
Larynx, typhoid affections of, 186, 

345- 
Lens, crystalline, typhoid affections 

of, 305. 
Leucocytosis, 218. 
Liver, abscess of, 244. 

typhoid affections of, 244. 
Lungs, typhoid affections of, 199. 



M. 
Malignant Edema, 295. 
Mediastinum, involvement of, 148, 

191, 192. 
Medico-legal obligations, 301. 
Meningitis, 152, 169. 
Mesenteric gland, abscess of, 162. 
Muscles, ocular, typhoid affections of, 
312. 

typhoid degeneration of, 371. 



N. 

Neuritis, optic, 306. 

retro-bulbar, 309. 

Neuro-retinitis, 310. 

Noma, 85. 

O. 

Optic nerve, typhoid affections of, 

306, 308. 
Orbit, phlegmon of, 311. 

typhoid affections of, 311. 
Orchitis, 279. 
Osteomyelitis, 127, 322. 
Otitis media, 181. 
Ovary, abscess of, 282. 

dermoid cyst of, 283. 

P. 

Paralysis of ocular muscles, 312. 
Parotidean sweating, 184. 
Parotitis, 1S3, 375. 

25 



Perforation of the gall-bladder, 262, 
325. 
of the intestines, 212. 

of the stomach, 206. 
Pericarditis, 200. 
Perichondritis, 194, 350. 
Perineum, gangrene of, 83, 369. 
Peritonitis, see Chapters VI, VII, 

XIV, XV, XVI, XVII, for its 

various causes. 
Phlebitis, 66. 
Pituitary body, suppuration about, 

3 2 4. 
Pleura, typhoid affections of, 199. 
Pott's disease and typhoid fever, 153. 
Pylephlebitis, 247. 



Rectum, perforation of, 83, 160. 
Retina, typhoid affections of, 306, 

3^9,310, 311. 
Ribs, typhoid disease of, 137 



S. 

Sexual organs, typhoid affections of 
female, 78, 282, 368. 
male, 78, 278, 368. 
Shattuck Lecture, 10, II. 
Sinus, cavernous, thrombosis of, 324. 
Skull, necrosis of, 344. 

osteomyelitis of, 322. 
Spleen, typhoid affections of, 274, 

326. 
Stomach, hemorrhage from, 206. 

perforation of, 206. 

ulcer of, 206. 
Sweating in parotid region, 1S4. 



Testicle, typhoid affections of, 279. 
Tetanus, 294. 
Thrombosis, arterial, 65. 
of orbital veins, 311. 



3 86 



INDEX. 



Thrombosis of peripheral vessels, 70. 
of Sylvian vein and cavernous 

sinuses, 324. 
venous, 66. 
Thyroid gland, typhoid infection of, 

186. 
Toner Lecture, 333. 
Typhoid fever, mixed infection in, 33. 
infection without intestinal 
lesions, 43, 321. 

U. 

Urethritis, 278. 

Uveal tract, typhoid affections of, 303. 



V. 

Vagina, lesions of, 79, 288, 368. 
Vein, Sylvian, thrombosis of, 324. 
Veins, intracranial, thrombosis of, 

176. 
Vitreous, typhoid affections of, 303, 

3°4- 
Vulva, lesions of, .79, 288, 368. 



X. 

Xerophthalmia, 302. 



CATALOGUE 

MEDICAL PUBLICATIONS 

OF 

W- B* SAUNDERS, 

No. 925 WALNUT STREET, PHILADELPHIA. 



Arranged Alphabetically and Classified under Subjects. 



' I 'tiE books advertised in this Catalogue as being sold by subscription are usually to be 
obtained from traveling solicitors, but they will be sent direct from the office of pub- 
lication (charges of shipment prepaid) upon receipt of the prices given. All the other 
books advertised are commonly for sale by booksellers in all parts of the United States ; 
but any book will be sent by the publisher to any address, carriage prepaid, on receipt of 
the published price. 

Money may be sent at the risk of the publisher in either of the following ways : 
A post-office money order, an express money order, a bank check, and in a registered 
letter. Money sent in any other way is at the risk of the sender. 



See pages 30, 3J, for a List of Contents classified according to subjects. 



LATEST PUBLICATIONS. 



Amer .Text-Book of Genito-Urinary and Skin Diseases. Page 3. 

MacdonalcTs Surgical Diagnosis, just Ready. See page 16. 

Anders' Practice of Medicine. See page 6. 

Moore's Orthopedic Surgery, just Ready. See page 17. 

Penrose's Diseases of Women. See page J8. 

Mallory and Wright's Pathological Technique. See page 16. 

Van Valzah and Nisbet's Diseases of the Stomach. See page 28. 

American Year-Book of Medicine and Surgery. See page 6. 

Senn's Genito-Urinary Tuberculosis. See page 25. 

Sutton and Giles' Diseases of Women. See page 28. 

Stoney's Nursing — Revised Edition. See page 27. 

Garrigues' Diseases of Women — Revised Edition. See page n. 

Keen's Surgical Complications of Typhoid Fever. See page 15. 

Gould and Pyle's Curiosities of Medicine. See page n. 

De Schweinitz' Diseases of the Eye — Revised Edition. Page jo. 

Chapin's Compendium of Insanity, just Ready. See page 8. 

Church and Peterson's Nervous and Mental Diseases. Page % 



SPECIAL ANNOUNCEMENT. 



Mr. Saunders is pleased to announce that arrangements have been completed for the 
publication of an English edition of the world-famous 

Lehmann medicinische Handatlanten. 

For scientific accuracy, pictorial beauty, compactness, and cheapness these books 
surpass any similar volumes ever published. Each volume contains from 

50 to 100 Colored Plates, 

besides numerous other illustrations in the text. These colored plates have been executed 
by the most skilful German lithographers, in some cases twenty or more impressions being 
required to obtain the desired result. There is a full and appropriate description of each 
plate (printed, for convenience, opposite the plate) , together with a condensed outline of 
the subject to which the book is devoted. 

The same careful and competent editorial supervision will be secured in the 
English edition as in the originals. The translations will be directed and edited by the 
leading American specialists in the different subjects. 

The great advantage of natural pictorial representation is indisputable. For lasting and 
practical knowledge, one accurate illustration is better than several pages of dry 
description. 

These Atlases offer a ready and satisfactory substitute for clinical observation, avail- 
able only to the residents of large medical centers ; and with such persons the requisite 
variety is seen only after long years of routine hospital service. 

By reason of their projected universal translation and reproduction, affording inter- 
national distribution, the publishers have been enabled to secure for these Atlases the best 
artistic and professional talent, to produce them in the most elegant style, and yet to 
offer them at a price heretofore unapproached in cheapness. The success of the under- 
taking is demonstrated by the fact that volumes have already appeared in German, English, 
French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. 

While appreciating the value of such colored plates, the profession has heretofore been 
practically debarred from purchasing similar works because of their extremely high price, 
made necessary by the limited sale and the enormous expense of production. The very 
low price of these Atlases will place them within the reach of even the novice in practice. 

The following volumes are in active preparation and will be issued at an early date : 

Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, 
of Erlangen. Edited by AUGUSTUS A. Eshner, M.D., Professor of Clinical Medicine 
in the Philadelphia Polyclinic ; Attending Physician to the Philadelphia Hospital. 
68 colored plates, and 64 illustrations in the text. 

Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by 
Frederick Peterson, M.D., Clinical Professor of Mental Diseases, Woman's 
Medical College, New York ; Chief of Clinic, Nervous Dept. , College of Physicians 
and Surgeons, New York. With 120 colored figures on 56 plates, and 193 beautiful 
half-tone illustrations. 

Atlas Of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by 
J. Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical 
College, Philadelphia ; Surgeon to the Philadelphia Hospital. With 24 colored plates, 
and 217 illustrations in the text. 

Atlas of Laryngology. By Dr. L. Grunwald, of Munich. With 107 colored 
figures on 44 plates ; 25 black-and-white illustrations. 

Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by 
G. E. DE Schweinitz, M.D., Professor of Ophthalmology, Jefferson Medical College, 
Philadelphia. With 100 colored illustrations. 

Atlas of Venereal Diseases. By. Dr. Karl Kopp, of Munich. Edited by L. 
Bolton Bangs, M.D., late Professor of Genito- Urinary and Venereal Diseases, New 
York Post-Graduate Medical School and Hospital. With 63 colored illustrations. 

Atlas of Skin Diseases. By Dr. Karl Kopp, of Munich. With 90 colored and 17 
black-and-white illustrations. 



Medical Publications of W. B. Saunders. 



AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS. 

Edited by James C. Wilson, M.D., Professor of the Practice of 

Medicine and of Clinical Medicine in the Jefferson Medical College, 
Philadelphia. One handsome imperial octavo volume of 1326 pa 
Illustrated. Cloth, $7.00 net; Sheep or Half Morocco, 58.00 net. 
Sold by Subscription. 

11 As a work cither for study or reference it will be of great value to the practitioner, as 
it is virtually an exposition of such clinical therapeutics as experience has taught to be of 
the most value. Taking it all in all, no recent publication on therapeutics can be compared 
with this one in practical value to the working physician." — Chicago Clinical Review. 

"The whole field of medicine has been well covered. The work is thoroughly prac- 
tical, and while it is intended for practitioners and students, it is a better book for the general 
practitioner than for the student. The young practitioner especially will find it extremely 
suggestive and helpful." — The Indian Lancet. 

AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN. 

Edited by Louis Starr, M.D., Physician to the Children's Hospital, 
Philadelphia, etc.; assisted by Thompson S. Westcott, M.D., Attend- 
ing Physician to the Dispensary for Diseases of Children, Hospital of 
the University of Pennsylvania. In one handsome imperial octavo 
volume of 1190 pages, profusely illustrated. Cloth, $7.00 net; Sheep 
or Half Morocco, $8.00 net. Sold by Subscription. 

"This is far and away the best text-book on children's diseases ever published in the 
English language, and is certainly the one which is best adapted to American readers. 
We congratulate the editor upon the result of his work, and heartily commend it to the 
attention of every student and practitioner." — American Journal of the Medical Sciences. 

" A condensation between the lids of a single volume of an amount of information upon 
childhood and its diseases which will be eagerly sought after by the profession." — New York 
Medical Times. 

AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
NOSE, AND THROAT. 

Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology 
in the Jefferson Medical College, Philadelphia ; and B. Alexander 
Randall, M.D., Professor of Diseases of the Ear in the University of 
Pennsylvania and in the Philadelphia Polyclinic. I?i Preparation. 

AN AMERICAN TEXT=BOOK OF GENITO=URINARY AND SKIN 
DISEASES. 

Edited by L. Bolton Bangs, M.D., Late Professor of Genito-Urinary 
and Venereal Diseases, New York Post-Graduate Medical School and 
Hospital ; and William A. Hardaway, M.D. , Professor of Diseases of 
the Skin, Missouri Medical College. In Press. Ready soon. 

This latest addition to the series of "American Text-Books" it is confidently believed will meet 
the requirements of both students and practitioners, giving, as it does, a comprehensive and detailed 
presentation of the Diseases of the Genito-Urinary Organs, of the Venereal Diseases, and of the 
Affections of the Skin. 

Having secured the collaboration of well-known authorities in the branches represented in the 
undertaking, the Editors have not restricted the Contributors in regard to the particular views set 
forth, but have offered every facility for the free expression of their individual opinions. The work 
will therefore be found to be original, yet homogeneous and fully representative of the several depart- 
ments of medical science with which it is concerned. 



Illustrated Catalogue of the "American Text-Books" sent free upon application* 



4 

4 Medical Publications of W. B. Saunders. 

AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND 
SURGICAL. 

Edited by J. M. Baldy, M.D., Professor of Gynecology in the Phila- 
delphia Polyclinic, etc. Handsome imperial octavo volume of over 
700 pages, with 360 illustrations in text, and 37 colored and half-tone 
plates. Cloth, $6.00 net; Sheep or Half Morocco, $7.00 net. Sold 
by Subscription. 

" The nature of the text may be judged from its authorship ; the distinguished American 
authorities who have compiled this publication have done their work well. It is well in- 
dexed, — an important feature in a work essentially intended for reference. . . . The 
work is very fully illustrated, and the wood-cuts and plates are of high excellence. . . . 
This addition to medical literature deserves favorable comment." — British Medical Journal. 

"It is practical from beginning to end. Its descriptions of conditions, its recommen- 
dations for treatment, and above all the necessary technique of different operations, are 
clearly and admirably presented. . . . It is well up to the most advanced views of the 
day, and embodies all the essential points of advanced American gynecology. It is destined 
to make and hold a place in gynecological literature which will be peculiarly its own." — 
Medical Record, New York. 

AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI= 
COLOGY. 

Edited by Frederick Peterson, M.D., Clinical Professor of Mental 
Diseases in the Woman's Medical College, New York ; Chief of Clinic, 
Nervous Department, College of Physicians and Surgeons, New York ; 
and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and 
Toxicology in Rush Medical College, Chicago. In Preparation. 

AN AMERICAN TEXT=BOOK OF OBSTETRICS. 

Edited by Richard C. Norris, M.D.; Art Editor, Robert L. Dick- 
inson, M.D. One handsome imperial octavo volume of over 1000 
pages, with nearly 900 beautiful colored and half-tone illustrations. 
Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Sub- 
scription. 

"Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
medical work that I have ever seen. I congratulate you and thank you for this superb work, 
which alone is sufficient to place you first in the ranks of medical publishers." — Alexander 
J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. V. 

" This is the most sumptuously illustrated work on midwifery that has yet appeared. In 
the number, the excellence, and the beauty of production of the illustrations it far surpasses 
every other book upon the subject. This feature alone makes it a work which no medical 
library should omit to purchase." — British Medical Journal. 

"The obstetrician and the general practitioner will find this book not only a pleasant 
and interesting volume, but the most valuable of its kind, both on account of the wide 
experience of the several authors and because of the attractiveness and accuracy of its 
illustrations. . . . As an authority, as a book of reference, as a ' working book ' for the 
student or practitioner, we commend it because we believe there is no better." — American 
Journal of the Medical Sciences. 

AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

Edited by John Guiteras, M.D., Professor of General Pathology and 
of Morbid Anatomy in the University of Pennsylvania; and David 
Riesman, M.D., Demonstrator of Pathological Histology in the 
University of Pennsylvania. In Preparation. 



Illustrated Catalogue of the "American Text-Books" sent free upon application. 



Medical Publications of W. B. Saunders. 



AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. 

Edited by William H. Howell, Ph.D., M.D., Professor of Physiology 
in the Johns Hopkins University, Baltimore, Md. One handsome 
imperial octavo volume of 1052 pages. Illustrated. Cloth, $6.00 
net; Sheep or Half Morocco, $7.00 net. Sold by Subscription. 

"The present volume constitutes practically a new departure in physiological text- 
books, on the lines which have already proved successful in medicine.' and surgery. Its value 
as a work of reference for the physician or pathologist is very great. We can commend it 
most heartily, not only to all students of physiology, but to every physician and pathologist, 
as a valuable and comprehensive work of reference, written by men who are of eminent 
authority in their own special subjects." — London Lancet. 

** To the practitioner of medicine and to the advanced student this volume constitutes, 
we believe, the best exposition of the present status of the science of physiology in the 
English language." — American Journal of the Medical Sciences. 

"The book is certainly the best thing in the way of physiological text-books that 
America has produced." — Edinburgh Medical Journal. 

AN AMERICAN TEXT=BOOK OF SURGERY. Second Edition. 

Edited by William W. Keen, M.D., LL.D., and J. William White, 
M.D., Ph.D. Handsome imperial octavo volume of 1250 pages, with 
500 wood-cuts in the text, and 39 colored and half-tone plates. 
Thoroughly revised and enlarged, with a section devoted to " The Use 
of the Rontgen Rays in Surgery." Cloth, $7.00 net; Sheep or Half 
Morocco, $8.00 net. Sold by Subscription. 

"Personally, I should not mind it being called THE Text-Book (instead of A Text- 
Book), for I know of no single volume which contains so readable and complete an account 
of the science and art of vSurgery as this does." — Edmund Owen, F. R.C.S., Member of the 
Board of Examiners of the Royal College of Sztrgeons, England. 

" If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefully to their laurels if they are to preserve a position in the van of surgical practice." — 
London Lancet. 

"This book marks an epoch in American book-making. All in all, the book is dis- 
tinctly the most satisfactory work on modern surgery with which we are familiar. It is 
thorough, complete, and condensed." — Boston Medical and Surgical Journal. 

AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
OF MEDICINE. 

Edited by William Pepper, M.D., LL.D., Professor of the Theory 
and Practice of Medicine and of Clinical Medicine in the University 
of Pennsylvania. Two handsome imperial octavo volumes of about 
1000 pages each. Illustrated. Prices per volume : Cloth, $5.00 net ; 
Sheep or Half Morocco, $6.00 net. Sold by Subscription. 

" I am quite sure it will commend itself both to practitioners and students of medicine, 
and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Pro- 
fessor of Pathology and Practice of Aledicine, University of the City of New York. 

" We reviewed the first volume of this work, and said: ' It is undoubtedly one of the 
best text-books on the practice of medicine which we possess.' A consideration of the 
second and last volume leads us to modify that verdict and to say that the completed work is 
in our opinion the best of its kind it has ever been our fortune to see." — New York Medical 
Journal. 

" American physicians can look with pride upon the work of Dr. Pepper and his corps 
of associates. It brings our krfowledge down to the present hour, and has been written 
from an eminently practical standpoint." — Medical Record, New York. 



Illustrated Catalogue of the "American Text-Books ** sent free upon application. 



6 Medical Publications of W. B. Saunders. 

AN AMERICAN YEAR=BOOK OF MEDICINE AND SURGERY. 

A Yearly Digest of Scientific Progress and Authoritative Opinion in all 
branches of Medicine and Surgery, drawn from journals, monographs, 
and text-books of the leading American and Foreign authors and 
investigators. Collected and arranged, with critical editorial com- 
ments, by eminent American specialists and teachers, under the general 
editorial charge of George M. Gould, M.D. One handsome imperial 
octavo volume of about 1200 pages. Uniform in style, size, and 
general make-up with the "American Text-Book" Series. Cloth, 
$6.50 net; Half Morocco, $7.50 net. Sold by Subscription. 

" It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, 
for, as each section is entrusted to experienced and able contributors, the reader has the 
advantage of certain critical commentaries and expositions . . . proceeding from writers 
fully qualified to perform these tasks. . . . It is emphatically a book which should find 
a place in every medical library, and is in several respects more useful than the famous 
' Jahrbiicher' of Germany." — London Lancet. 

ANDERS' PRACTICE OF MEDICINE. 

A Text=Book of the Practice of Medicine. By James M. Anders, 
M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of 
Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one 
handsome octavo volume of 1287 pages, fully illustrated. Cloth, 
$5.50 net; Sheep or Half Morocco, $6.50 net. 

" We know of no recent author who has as effectively succeeded in bringing the new 
facts and ideas together, weaving them with the substantial realities of the old, in better form. 
The concise character of the text, the clearness with which its ideas are expressed, the 
ingenious arrangement of its data, the completeness of its detail, the order of sequence of 
its topics, and the whole general appearance of the volume tell of careful, conscientious work 
done by him. His tables for aiding in differential diagnosis, his association of clinical symp- 
toms with the morbid lesions that accompany them, his tested therapeutic formulae, his appro- 
priate illustrations, his bacteriology, and his modern orthography have made of it a fully up- 
to-date, handy text-book for the general practitioner." — American Medico- Surgical Bulletin. 

ASHTON'S OBSTETRICS. Third Edition, Revised. 

Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- 
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
Crown octavo, 2 5 2 pages ; 75 illustrations. Cloth, $1.00; interleaved 
for notes, $1.25. 

[See Saunders'' Question- Compends, page 21.] 

" Embodies the whole subject in a nut-shell. We cordially recommend it to our read- 
ers." — Chicago Medical Times. 

BALL'S BACTERIOLOGY. Third Edition, Revised. 

Essentials of Bacteriology ; a Concise and Systematic Introduction 
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- 
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 
pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; 
interleaved for notes, $1.25. 

[See Saunders 1 Question- Compends, page 21.] 

" The student or practitioner can readily obtain a knowledge of the subject from a perusal 
of this book. The illustrations are clear and satisfactory." — Medical Record, New York. 



Medical Publications of W. B. Saunders. 



BASTIN'S BOTANY. 

Laboratory Exercises in Botany. By Edson S. Bastin, M. A., 

late Professor of Materia Medica and Botany, Philadelphia College of 
Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, 32.50. 

" Tt is unquestionably the best text-book on tbc subject that has yet appeared. The 
work is eminently a practical one. We regard the issuance of this book as an important 
event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
fied success." — Alumni Report to the Philadelphia College of Pharmacy. 

" There is no work like it in the pharmaceutical or botanical literature of this country, 
and we predict for it a wide circulation." — American Journal of Pharmacy. 

BECK'S SURGICAL ASEPSIS. 

A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to 
St. Mark's Hospital and the New York German Poliklinik, etc. 306 
pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net. 

" An excellent exposition of the ' very latest ' in the treatment of wounds as practised 
by leading German and American surgeons." — Birmingham (Eng. ) Medical Review. 

"This little volume can be recommended to any who are desirous of learning the details 
of asepsis in surgery, lor it will serve as a trustworthy guide." — London Lancet. 

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
OPERATIONS. 
Obstetric Accidents, Emergencies, and Operations. By L. Ch. 

Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis 
Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. 

" Tt is clearly and concisely written, and is evidently the work of a teacher and practi- 
tioner of large experience." — British Medical Journal. 

" A manual so useful to the student or the general practitioner has not been brought to 
our notice in a long time. The field embraced in the title is covered in a terse, interesting 
way." — Yale Medical Journal. 

BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
Essentials of Medical Physics. By Fred J. Brockway, M.D., 
Assistant Demonstrator of Anatomy in the College of Physicians and 
Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations. 
Cloth, $1.00 net ; interleaved for notes, $1.25 net. 

[See Saunders 7 Question- Compends, page 21.] 

" The student who is well versed in these pages will certainly prove qualified to com- 
prehend with ease and pleasure the great majority of questions involving physical principles 
likely to be met with in his medical studies." — American Practitioner and News. 

"We know of no manual that affords the medical student a better or more concise 
exposition of physics, and the book may be commended as a most satisfactory presentation 
of those essentials that are requisite in a course in medicine." — New York Medical Journal. 

" It contains all that one need know on the subject, is well written, and is copiously 
illustrated." — Medical Record, New York. 

BURR ON NERVOUS DISEASES. 

A Manual of Nervous Diseases. By Charles W. Burr, M.D., 
Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary 
for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. 
In Preparation. 



8 Medical Publications of W. B. Saunders. 

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR= 
MACOLOGY. 
A Text=Book of Materia Medica, Therapeutics, and Pharma= 
cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
Medica and of Clinical Medicine in the College of Physicians and 
Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, 
Northwestern University, Woman's Medical School, etc. Octavo, 858 
pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 

A clear, concise, and practical text-book, adapted for permanent reference no less than 
for the requirements of the class-room. The arrangement (embodying the synthetic classifi- 
cation of drugs based upon therapeutic affinities) is believed to be at once the most philo- 
sophical and rational, as well as that best calculated to engage the interest of those to whom 
the academic study of the subject is wont to offer no little perplexity. Special attention has 
been given to the Pharmaceutical section, which is exceptionally lucid and complete. 

CASSELBERRY ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By W. E. Casselberry, Pro- 
fessor of Laryngology and Rhinology in the Northwestern University 
Medical School, Chicago. In Preparation. 

CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
Notes on the Newer Remedies, their Therapeutic Applications 
and Modes of Administration. By David Cerna, M.D., Ph.D., 
formerly Demonstrator of and Lecturer on Experimental Therapeutics 
in the University of Pennsylvania ; Demonstrator of Physiology in the 
Medical Department of the University of Texas. Rewritten and 
greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. 

"These ' Notes ' will be found very useful to practitioners who take an interest in the 
many newer remedies of the present day." — Edinburgh Medical Journal. 

" The appearance of this new edition of Dr. Cerna's very valuable work shows that it 
is properly appreciated. The book ought to be in the possession of every practising physi- 
cian." — New York Medical Journal. 

CHAPIN ON INSANITY. 

A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 

Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
cian-Superintendent of the Willard State Hospital, New York ; Hon- 
orary Member of the Medico-Psychological Society of Great Britain, 
of the Society of Mental Medicine of Belgium, etc. In Preparation. 

The author has given, in a condensed and concise form, a compendium of Diseases of 
the Mind, for the convenient use and aid of physicians and students. The work will also 
prove valuable to members of the legal profession and to those who, in their relations to the 
insane and to those supposed to be insane, often desire to acquire some practical knowledge 
of insanity presented in a form that may be understood by the non-professional reader. 

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
Second Edition, Revised. 
Medical Jurisprudence and Toxicology. By Henry C. Chapman, 
M.D., Professor of Institutes of Medicine and Medical Jurisprudence 
in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
illustrations and 3 full-page plates in colors. Cloth, $1.50 net. 

"The best book of its class for the undergraduate that we know of." — New York 
Medical Times. 






Medical Publications of W. B. Saunders. 



CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
Nervous and Mental Diseases. By Archibald Church, M.D., 
Professor of Mental Diseases and Medical Jurisprudence in the North- 
western University Medical School, Chicago; and Frederick Peter- 
son, M.D., Clinical Professor of Mental Diseases in the Woman's 
Medical College, New York; Chief of Clinic, Nervous Department, 
College of Physicians and Surgeons, New York. In Preparation. 

CLARKSON'S HISTOLOGY. 

A Text=Book of Histology, Descriptive and Practical. By 

Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
Physiology in the Owen's College, Manchester ; late Demonstrator of 
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
22 engravings in the text, and 174 beautifully colored original illustra- 
tions. Cloth, strongly bound, 36.00 net. 

"The work must be considered a valuable addition to the list of available text-books, 
and is to be highly recommended." — Nero York Medical Journal. 

" This is one of the best works for students we have ever noticed. We predict that the 
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

"The volume is a most valuable addition to the armamentarium of the teacher." — 
Brooklyn Medical Journal. 

CLIMATOLOGY. 

Transactions of the Eighth Annual Meeting of the American 
Climatological Association, held in Washington, September 22-25, 
1891. Forming a handsome octavo volume of 276 pages, uniform with 
remainder of series. (A limited quantity only.) Cloth, $1.50. 

COHEN AND ESHNER'S DIAGNOSIS. 

Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
phia Polyclinic; and Augustus A. Eshner, M.D., Instructor in Clinical 
Medicine, Jefferson Medical College, Philadelphia. Post-octavo, 382 
pages; 55 illustrations. Cloth, $1.50 net. 

[See Saunders' Question- Compends, page 21.] 

"We can heartily commend the book to all those who contemplate purchasing a 'com- 
pend.' It is modern and complete, and will give more satisfaction than many other works, 
which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 

CORWIN'S PHYSICAL DIAGNOSIS. 

Essentials of Physical Diagnosis of the Thorax. By Arthur 
M. Corwin, A.M., M. D., Demonstrator of Physical Diagnosis in Rush 
Medical College, Chicago ; Attending Physician to Central Free Dis- 
pensary, Department of Rhinology, Laryngology, and Diseases of the 
Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. 

"It is excellent. The student who shall use it as his guide to the careful study of 
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
working knowledge of the subject." — Philadelphia Polyclinic. 

"A most excellent little work. It brightens the memory of the differential diagnostic 
signs, and it arranges orderly and in sequence the various objective phenomena to logical 
solution of a careful diagnosis." — Journal of Nervous and Mental Diseases. 



10 Medical Publications of W. B. Saunders. 

CRAGIN'S GYNAECOLOGY. Fourth Edition, Revised. 

Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- 
ing Gynaecologist, Roosevelt Hospital, Out-Patients' Department, New 
York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, 
$t.oo; interleaved for notes, $1.25. 

[See Saztnders' Question- Compends, page 21.] 

' ' A handy volume, and a distinct improvement on students' compends in general. No 
author who was not himself a practical gynecologist could have consulted the student's needs 
so thoroughly as Dr. Cragin has done." — Medical Record, New York. 

CROOKSHANK'S BACTERIOLOGY. 

A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
Professor of Comparative Pathology and Bacteriology, King's College, 
London. Octavo volume of 700 pages, with 273 engravings and 22 
original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. 

" To the student who wishes to obtain a good resume of what has been done in bacteri- 
ology, or who wishes an accurate account of the various methods of research, the book may 
be recommended with confidence that he will find there what he requires." — London Lancet. 

DaCOSTA'S SURGERY. 

A Manual of Surgery, General and Operative. By John 
Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson 
Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, 
etc. Handsome volume of 810 pages; 188 illustrations in the text, 
and 13 full-page plates in colors. Cloth, $2.50 net. 

"We know of no small work on surgery in the English language which so well fulfils 
the requirements of the modern student." — Medico- Chirurgical Journal, Bristol, England. 

DE SCHWEINITZ ON DISEASES OF THE EYE. Second Edition, 
Revised. 
Diseases of the Eye, A Handbook of Ophthalmic Practice. 

By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the 
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
volume of 679 pages, with 256 fine illustrations and 2 chromo-litho- 
graphic plates. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. 

" A clearly written, comprehensive manual. One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering 
•upon the study of this special branch of medical science." — British Medical Journal. 

" A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine y 
University of Pennsylvania. 

DORLAND'S OBSTETRICS. 

A Manual of Obstetrics. By W. A. Newman Dorland, M.D., 
Assistant Demonstrator of Obstetrics, University of Pennsylvania; 
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. 

" liy far the best book on this subject that has ever come to our notice." — American 
Medical Review. 

" It has rarely been our duty to review a book which has given us more pleasure in its 
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
a gold mine of practical, concise thoughts." — American Medico-Surgical Bulletin. 



Medical Publications of W. B. Saunders. 1 1 



FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 

Laboratory Guide for the Bacteriologist. By Lw >don Froth- 
INGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science, 
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 

"It is a convenient and useful little work, and will more than repay the outlay neces- 
sary for its purchase in the saving of time which would otherwise be consumed in looking 
up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
can Medico- Surgical Bulletin. 

GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. 
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
fessor of Gynecology and Obstetrics in the New York School of 
Clinical Medicine; Gynecologist to St. Mark's Hospital and to the 
German Dispensary, New York City, etc. Handsome octavo volume 
of 728 pages, illustrated by 335 engravings and colored plates. Cloth, 
$4.00 net; Sheep or Half Morocco, $5.00 net. 

" One of the best text-books for students and practitioners which has been published in 
the English language ; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners to whom experienced consultants 
may not be available will find in this book invaluable counsel and help." — Thad. A. 
REAMY, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. 

GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
ment of the Northern Dispensary, Philadelphia. 208 pages, with 
114 illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. 
[See Saunders* Question- Compends, page 21.] 

"It is just the book to put into the hands of a student, and cannot fail to give him a 
useful introduction to ear- affections ; while the style of question and answer which is adopted 
throughout the book is, we believe, the best method of impressing facts permanently on the 
mind. " — Liverpool Medico- Chirurgical Journal. 

GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 

Anomalies and Curiosities of Medicine. By George M. Gould, 
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
rare and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an 
exhaustive research of medical literature from its origin to the present 
day, abstracted, classified, annotated, and indexed. Handsome im- 
perial octavo volume of 968 pages, with 295 engravings in the text, 
and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. 
Sold by Subscription. 

" One of the most valuable contributions ever made to medical literature. It is, so far 
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
the medical profession has this volume value : it will serve as a book of reference for all who 
are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
Journal. 

"This is certainly a most remarkable and interesting volume. It stands alone among 
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
medical literature. It is a book full of revelations from its first to its last page, and cannot 
but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 



12 Medical Publications of W. B. Saunders. 

GRIFFINS MATERIA MEDICA AND THERAPEUTICS. 

Manual of Materia Medica and Therapeutics. By Henry A. 
Griffin, A.B., M.D., Assistant Physician to the Roosevelt Hospital, 
Out-Patient Department, New York City. In Preparation. 

GRIFFITH ON THE BABY. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
cal Professor of Diseases of Children, University of Pennsylvania ; 
Physician to the Children's Hospital, Philadelphia, etc. 121110, 392 
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. 

" The best book for the use of the young mother with which we are acquainted. . . . 
There are very few general practitioners who could not read the book through with advan- 
tage." — Archives of Pediatrics. 

"The whole book is characterized by rare good sense, and is evidently written by a 
master hand. It can be read with benefit not only by mothers but by medical students and 
by any practitioners who have not had large opportunities for observing children." — Ameri- 
can Journal of Obstetrics. 

GRIFFITH'S WEIGHT CHART. 

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. , 
Clinical Professor of Diseases of Children in the University of Penn- 
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first two years 
of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
so that any deviation from the normal can readily be detected. 

GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 

Autobiography of Samuel D. Gross, M.D., Emeritus Professor of 
Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
niscences of His Times and Contemporaries. Edited by his Sons, 
Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- 
gery and of Clinical Surgery in the Jefferson Medical College, and 
A. Hauler Gross, A.M., of the Philadelphia Bar. Preceded by a 
Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
two handsome volumes, each containing over 400 pages, demy octavo, 
extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
per volume, $2.50 net. 

" Dr. Gross was perhaps the most eminent exponent of medical science that America 
has yet produced. His Autobiography, related as it is with a fulness and completeness 
seldom to be found in such works, is an interesting and valuable book. He comments on 
many things, especially, of course, on medical men and medical practice, in a very interest- 
ing way.'* — The Spectator, London, England. 

HAMPTON'S NURSING. 

Nursing : Its Principles and Practice. By Isabel Adams Hamp- 
ton, Graduate of the New York Training School for Nurses attached 
to Bellevue Hospital ; Superintendent of Nurses, and Principal of the 
Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 
i2mo, 484 pages, profusely illustrated. Cloth, $2.00 net. 

" Seldom have we perused a book upon the subject that has given us so much pleasure 
as the one before us. We would strongly urge upon the members of our own profession the 
need of a book like this, for it will enable each of us to become a training school in him- 
self. ' ' — Ontario Medical Journal. 



Medical Publications of W. B. Saunders. 13 



HARE'S PHYSIOLOGY. Fourth Edition, Revised. 

Essentials of Physiology. By H. A. Hare, M.I)., Professor of 
Therapeutics and Materia Medica in the Jefferson Medical College of 
Philadelphia; Physician to the Jefferson Medical College Hospital. 
Containing a series of handsome illustrations from the celebrated 
" Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages. 
Cloth, $1.00 net; interleaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

" The best condensation of physiological knowledge we have yet seen." — Medical 
Record ', New York. 

HART'S DIET IN SICKNESS AND IN HEALTH. 

Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
Student of the Faculty of Medicine of Paris and of the London School 
of Medicine for Women ; with an Introduction by Sir Henry 
Thompson, F.R.C.S., M.D., London. 220 pages ; illustrated. Cloth, 
$1.50. 

" We recommend it cordially to the attention of all practitioners ; both to them and to 
their patients it may be of the greatest service." — New York Medical Journal. 

HAYNES' ANATOMY. 

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
ment of the New York University, etc. 680 pages, illustrated with 42 
diagrams in the text, and 134 full-page half-tone illustrations from 
original photographs of the author's dissections. Cloth, $2.50 net. 

11 This book is the work of a practical instructor — one who knows by experience the 
requirements of the average student, and is able to meet these requirements in a very satis- 
factory way. The book is one that can be commended." — Medical Record, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D. , Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
Jn Preparation. 

HIRSTS OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., 
Professor of Obstetrics in the University of Pennsylvania. In Prepa- 
ration. 

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
DISEASES. 
Syphilis and the Venereal Diseases. By James Nevins Hyde, 
M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
gomery, M.D., Lecturer on Dermatology and Genito-L-rinary Diseases 
in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. 
Cloth, $2.50 net. 

" We can commend this manual to the student as a help to him in his study of venereal 
diseases. ' ' — Liverpool Medico- Chirurgical Journal. 

"The best student's manual which has appeared on the subject." — St. Louis Medical 
and Surgical Journal. 



14 Medical Publications of W. B. Saunders. 

JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
THROAT. Second Edition, Revised. 
Essentials of Refraction and Diseases of the Eye. By Edward 
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine ; and — 
Essentials of Diseases of the Nose and Throat. By E. Bald- 
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and 
Ear Department of the Northern Dispensary of Philadelphia. Two 
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
Si. 00; interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

" Of great value to the beginner in these branches. The authors are both capable men, 
and know what a student most needs." — Medical Record, New York. 

KEATING'S DICTIONARY. Second Edition, Revised. 

A New Pronouncing Dictionary of Medicine, with Phonetic 
Pronunciation, Accentuation, Etymology, etc. By John M. 
Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
delphia ; Vice-President of the American Paediatric Society ; Editor 
''Cyclopaedia of the Diseases of Children," etc.; and Henry 
Hamilton, Author of " A New Translation of Virgil's ^Eneid into 
English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
Costa, M.D., and Frederick A. Packard, M.D. With an Appendix 
containing Tables of Bacilli, Micrococci, Leucomaines, Ptomaines; 
Drugs and Materials used in Antiseptic Surgery; Poisons and their 
Antidotes; Weights and Measures; Thermometric Scales; New 
Official and Unofficial Drugs, etc. One volume of over 800 pages. 
Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 
net; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net. 
Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, 
$5.00 net. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
ing it to my classes." — Henry M. Lyman, M.D., Professor of the P}-inciples and Pi-actice 
of Medicine, Rush Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient 
in size and sufficiently full for ordinary use." — C. A. Lindsley, M.D., Professor of the 
Theory and Practice of Medicine, Medical Dept. Yale University. 

KEATING'S LIFE INSURANCE. 

How to Examine for Life Insurance. By John M. Keating, M.D., 
Fellow of the College of Physicians and Surgeons of Philadelphia; 
Vice-President of the American Psediatric Society ; Ex- President of 
the Association of Life Insurance Medical Directors. Royal octavo, 
211 pages; with two large half-tone illustrations, and a plate prepared 
by Dr. McClellan from special dissections ; also, numerous other 
illustrations. Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, 
a subject of growing interest and importance. Not the least valuable portion of the volume 
is Part II, which consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. If for these alone, the book should be at the right 
hand of every physician interested in this special branch of medical science." — The Medical 
News. 



Medical Publications of W. B. Saunders. 15 



KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Typhoid Fever. 
By \Y.\i. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
Corresponding Member of the Societe de Chirurgie, Paris j Honorary 
Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
about 400 pages. Cloth, £3.00 net. Nearly Ready. 

This monograph is the only one in any language covering the entire subject of the 
Surgical Complications and Sequels of Typhoid lever. It will prove to be of import 
and interest not only to the general surgeon and physician, but also to many specialists — laryn- 
gologists, gynecologists, pathologists, and bacteriologists. 

KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
An Operation Blank, with Lists of Instruments, etc. Required 
in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 

Professor of the Principles of Surgery in Jefferson Medical College, 
Philadelphia. Price per pad, containing blanks for fifty operations, 
50 cents net. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
Chief Laryngologist to St. Agnes' Hospital, Philadelphia; Bacteri- 
ologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases ; 
Instructor in Clinical Microscopy and Assistant Demonstrator of 
Pathology in the Jefferson Medical College, etc. In Preparation. 

LAINE'S TEMPERATURE CHART. 

Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ 
inches. A conveniently arranged Chart for recording Temperature, 
with columns for daily amounts of Urinary and Fecal Excretions, 
Food, Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. Price, per pad 
of 25 charts, 50 cents net. 

" To the busy practitioner this chart will be found of great value in fever cases, and 
especially for cases of typhoid.'' — Indian Lancet, Calcutta. 

LOCKWOOD'S PRACTICE OF MEDICINE. 

A Manual of the Practice of Medicine. By George Roe Lock- 
wood, M.D., Professor of Practice in the Woman's Medical College 
of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
the text, and 22 full-page plates. Cloth, $2.50 net. 

" Gives in a most concise manner the points essential to treatment usually enumerated 
in the most elaborate works." — Massachitsetts Medical Journal. 

LONG'S SYLLABUS OF GYNECOLOGY. 

A Syllabus of Gynecology, arranged in Conformity with " An 
American Text=Book of Gynecology." By J. W. Long, M.D., 
Professor of Diseases of Women and Children, Medical College of 
Virginia, etc. Cloth, interleaved, £1.00 net. 

" The book is certainly an admirable resume of what every gynecological student and 
practitioner should know, and will prove of value not only to those who have the ' American 
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 



16 Medical Publications of W. B. Saunders. 

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
Edin., L.R. C.S., Edin., Professor of the Practice of Surgery and of 
Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, 
$6.00 net. 

" The rapid advances made in the art of surgery have caused the literature of the science 
to grow apace. Systems of surgery in many volumes, and text-books of large dimensions, 
are now deemed necessary to cover the field. The practical part of the surgeon's work is, 
however, almost limited to two questions which he must answer every time his professional 
advice or help is sought. The first question is, ' What is the disease or injury ? ' The 
second question is, ' What is the proper treatment ? ' 

"While I would not for a moment underestimate the importance of a profound study 
of the principles of surgery, of surgical pathology, or of bacteriology, the present work will 
be confined to a solution of the two questions just mentioned, with the view of putting into 
the hands of students and practitioners a single volume containing the most practical part 
of practical surgery." — Front the Author' 's Preface. 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 

Pathological Technique. By Frank B. Mallory, A.M., M.D., 
Assistant Professor of Pathology, Harvard University Medical School ; 
and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard 
University Medical School. Octavo volume of 396 pages, handsomely 
illustrated. Cloth, $2.50 net. 

" I have been looking forward to the publication of this book, and I am glad to say that 
I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni- 
versity, Baltimore, Md. 

MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
DISEASES. Second Edition, Revised. 
Essentials of Minor Surgery, Bandaging, and Venereal 
Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
octavo, 166 pages, with 78 illustrations. Cloth, $1.00 ; interleaved for 
notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

"A very practical and systematic study of the subjects, and shows the author's famil- 
iarity with the needs of students." — Therapeutic Gazette. 

MARTIN'S SURGERY. Sixth Edition, Revised. 

Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
cal Landmarks, Minor and Operative Surgery, and a complete de- 
scription, with illustrations, of the Handkerchief and Roller Bandages. 
By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
pages, illustrated. With an Appendix containing full directions for the 
preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
$1.00; interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

"Contains all necessary essentials of modern surgery in a comparatively small space. 
Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter, o 



Medical Publications of W. B. Saunders. 17 



MCFARLAND'S PATHOGENIC BACTERIA. 

Text-Book upon the Pathogenic Bacteria. Specially written 
for Students of Medicine. By Joseph McFarland, M.D., Pro- 
fessor of Pathology and Bacteriology in the Medico-Chirurgical College 
of Philadelphia, etc. Octavo volume of 359 pages, finely illustrated. 
Cloth, $2.50 net. 

" Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
presenting in a concise and readable form the essentials of bacteriology up to date. Alto 
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
students of Trinity College." — H. B. Anderson, M.D., Professor of Pathology and Bac- 
teriology, Trinity Medical College, Toronto. 

MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
in limp cloth, flush edges, 25 cents net. 

"This pamphlet is worth many times over its price to the physician. The author's 
experiments and conclusions are original, and have been the means of doing much good." — 

Medical Bulletin. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo 
volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. 

A practical book based upon the author's experience, in which special stress is laid 
upon early diagnosis, and treatment such as can be carried out by the general practitioner. 
The teachings of the author are in accordance with his belief that true conservatism is to 
be found in the middle course between the surgeon who operates too frequently and the 
orthopedist who seldom operates. 

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fourth 
Edition, Revised. 
Essentials of Materia Medica, Therapeutics, and Prescription- 
Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
of Physicians, Philadelphia, etc. Crown octavo, 250 pages. Cloth, 
$1.00; interleaved for notes, $1.25. 

[See Saunders'' Question- Compends, page 21.] 

" This work, already excellent in the old edition, has been largely improved by revi- 
sion." — American Practitioner and News. 

MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
Third Edition, Revised. 
Essentials of the Practice of Medicine. By Henry Morris, M.D., 
late Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia; with an Appendix on the Clinical and Microscopic Examina- 
tion of Urine, by Lawrence Wolff, M.D. , Demonstrator of Chemistry, 
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
tial formulae collected and arranged by William M. Powell, M.D. 
Post-octavo, 488 pages. Cloth, $2.00. 

[See Saunders'' Question- Compends , page 21.] 

" The teaching is sound, the presentation graphic ; matter full as can be desired, and 
style attractive." — American Practitioner and News. 



18 Medical Publications of W. B. Saunders. 

MORTEN'S NURSE'S DICTIONARY. 

Nurse's Dictionary of Medical Terms and Nursing Treat- 
ment. Containing Definitions of the Principal Medical and Nursing 
Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
dents, Treatments, Operations, Foods, Appliances, etc. encountered 
in the ward or in the sick-room. By Honnor Morten, author of 
"How to Become a Nurse," etc. 161110, 140 pages. Cloth, $1.00. 

" A handy, compact little volume, containing a large amount of general information, all 
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 

NANCREDE'S ANATOMY. Fifth Edition. 

Essentials of Anatomy, including the Anatomy of the Viscera. 
By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- 
cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 
388 pages; 180 illustrations. With an Appendix containing over 60 
illustrations of the osteology of the human body. Based upon Gray's 
Anatomy. Cloth, $1. 00; interleaved for notes, $1.25. 
[See Saunders' Question- Compends , page 21.] 

" For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at 
school, it would not be easy to speak of it in terms too favorable." — American Practitioner. 

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
Essentials of Anatomy and Manual of Practical Dissection. 

By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical 
Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 pages, 
with full-page lithographic plates in colors, and nearly 200 illustrations. 
Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. 

" It may in many respects be considered an epitome of Gray's popular work on general 
anatomy, at the same time having some distinguishing characteristics of its own to commend 
it. The plates are of more than ordinary excellence, and are of especial value to students 
in their work in the dissecting room." — Journal of the American Medical Association. 

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. 
Syllabus of Obstetrical Lectures in the Medical Department 
of the University of Pennsylvania. By Richard C. Norris, 
A.M., M.D., Demonstrator of Obstetrics, 'University of Pennsylvania. 
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 

"This work is so far superior to others on the same subject that we take pleasure in 
calling attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner." — Medical Record, New York. 

PENROSE'S DISEASES OF WOMEN. 

A Text=Book of Diseases of Women. By Charles B. Penrose, 
M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- 
vania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. 

" The book is to be commended without reserve, not only to the student but to the 
general practitioner who wishes to have the latest and best modes of treatment explained 
with absolute clearness." — Therapeutic Gazette. 

" Taking it all in all, this is in our opinion one of the best works upon this subject that 
has appeared, and Mr. Saunders may feel justly proud of having the work issued from his 
press. ' ' — Matthews' 1 Quarterly Journal. 



Medical Publications of W. B. Saunders. 19 



POWELL'S DISEASES OF CHILDREN. Second Edition. 

Essentials of Diseases of Children. By William M. Powell, 

M.D., Attending Physician to the Mercer House for Invalid Women 
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseasi 
Children in the Hospital of the University of Pennsylvania. Crown 
octavo, 222 pages. Cloth, $1.00; interleaved for notes, $1-25. 

[See San infers' Question- Compends, page 21.] 

"Contains the gist of all the best works in the department to which it relates." — 
American Practitioner and News. 

PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
Pictorial Atlas of Skin Diseases and Syphilitic Affections 
(American Edition). Translation from the French. Edited by 
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex 
Hospital, London. Photo-lithochromes from the famous models in 
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
cuts and text. Complete in 12 Parts. Price per Part, $3.00. 

" I strongly recommend this Atlas. The plates are exceedingly well executed, and will 
be of great value to all studying dermatology." — Stephen Mackenzie, M.D. (London 
Hospital). 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier' understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal. 

PYE'S BANDAGING. 

Elementary Bandaging and Surgical Dressing. With Direc- 
tions concerning the Immediate Treatment of Cases of Emergency. 
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late 
Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 

" The directions are clear and the illustrations are good." — London Lancet. 
" The author writes well, the diagrams are clear, and the book itself is small and port- 
able, although the paper and type are good." — British Medical Journal. 

RAYMOND'S PHYSIOLOGY. 

A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
Professor of Physiology and Hygiene and Lecturer on Gynecology in 
the Long Island College Hospital ; Director of Physiology in the 
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
text, and 4 full -page colored plates. Cloth, $1.25 net. 

" Extremely well gotten up, and the illustrations have been selected with care. The 
text is fully abreast with modern physiology." — British Medical Journal. 

RONTGEN RAYS. 

Archives of the Rontgen Ray (Formerly Archives of Clinical 
Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and 
W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, 
with descriptive text, illustrating the applications of the new photo- 
graphy to Medicine and Surgery. Price per Part, $1.00. Now ready: 
Vol. I., Parts I. to IV. ; Vol. II., Part I. 




Saunders' 
Question 



Arranged in Question and 
Answer Form. 



q-* HE MOST COMPLETE AND BEST 

f^OftTTO'PlVrnC ILLUSTRATED SERIES OF 

V^UIYLl lliNUo COMPENDS EVER ISSUED. 

Now the Standard Authorities in Medical Literature 

with Students and Practitioners in every City of the United States and Canada. 



CL- 



OVER \ 65,000 COPIES SOLD. 



THE REASON WHY. 

They are the advance guard of "Student's Helps" — that DO HELP. They are the 
leaders in their special line, well and authoritatively written by able men, who, as teachers in 
the large colleges, know exactly what is wanted by a student preparing for his examinations. 
The judgment exercised in the selection of authors is fully demonstrated by their professional 
standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of 
them have become Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches) , containing on an average 250 pages, 
profusely illustrated, and elegantly printed in clear, readable type, on fine paper. 

The entire series, numbering twenty-three volumes, has been kept thoroughly revised 
and enlarged when necessary, many of the books being in their fifth and sixth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of 
them approach the "Blue Series of Question Compends;" and the claim is made for the 
following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Quality of illustrations, paper, printing, and binding. 

Any cf these Compends will be mailed on receipt of price (see next page for List). 



oaunders' Question-Compend Series< 

Price, Cloth, $1.00 per copy, except when otherwise noted. 



"Where the work of preparing students' manuals is to end we cannot say, hut the 
Saunders Series, in our opinion, bears off the palm at present."— New York Medical J 



1. ESSENTIALS OF PHYSIOLOGY. By H. A. Mark, M.D. Fourth edition, 

revised and enlarged. (Si.oo net.) 

2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, 

revised, with an Appendix on Antiseptic Surgery. 

3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth 

edition, with an Appendix. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

By LAWRENCE WOLFF, M.D. Fourth edition, revised, witli an Appendix. 

5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.I). Fourth 

edition, revised and enlarged. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C E. 

Arm and SEMPLE, M.D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION= WRITING. By Henry Morris, M.D. Fourth edition, revised. 

8,9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 
M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
Third edition, enlarged by some 300 Essential Formula;, selected from eminent 
authorities, by \Ym. M. Powell, M.D. (Double number, $2.00.) 

10. ESSENTIALS OF GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth 

edition, revised. 

11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 

M. I). Third edition, revised and enlarged. ($1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 

DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

By C. E. Armand Semple, M.D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 

15. ESSENTIALS OF DISEASES OF CHILDREN. By William M Powell, 

M. D. Second edition. 

16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 

M.D. Colored " Vogel Scale." (75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, 

M.D. (Si. 50 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 

Second edition, revised and enlarged. 

20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, 

revised. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 

Shaw, M.D. Third edition, revised. 

22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brock way, M.D. 

Second edition, revised. (Si. 00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. By Dayid D. Stewart, M.D., 

and Edward S. Lawrance, M.D. 

24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. 

Second edition, revised and greatly enlarged. 



Pamphlet containing specimen pages, etc. sent free upon application. 



PRACTICAL. EXHAUSTIVE, AUTHORITATIVE. 



SAUNDERS' 

New Series of Manuals 



FOR 



STUDENTS AND PRACTITIONERS. 



'F'HAT there exists a need for thoroughly reliable hand-books on 
the leading branches of Medicine and Surgery is a fact amply 
demonstrated by the favor with which the SAUNDERS NEW 
SERIES OF MANUALS have been received by medical students 
and practitioners and by the Medical Press* These manuals are not 
merely condensations from present literature, but are ably written by 
well-known authors and practitioners, most of them being teachers in 
representative American colleges* Each volume is concisely and author- 
itatively written and exhaustive in detail, without being encumbered 
with the introduction of "cases," which so largely expand the ordinary 
text-book* These manuals will therefore form an admirable collection 
of advanced lectures, useful alike to the medical student and the prac- 
titioner : to the latter, too busy to search through page after page of 
elaborate treatises for what he wants to know, they will prove of ines- 
timable value ; to the former they will afford safe guides to the essen- 
tial points of study* 

The SAUNDERS NEW SERIES OF MANUALS are con- 
ceded to be superior to any similar books now on the market. No 
other manuals afford so much information in such a concise and avail- 
able form* A liberal expenditure has enabled the publisher to render 
the mechanical portion of the work worthy of the high literary stand- 
ard attained by these books. 



Saunders' New Series of Manuals* 



VOLUMES PUBLISHED. 

PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
and Hygiene and Lecturer on Gynecology in the Long island College Hospital; 
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. 

SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- 
cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the 

Philadelphia Hospital, etc. 188 illustrations and 13 plates. ' (Double number.) < loth, 
52.50 net. 

DOSE-BOOK AND MANUAL OF PRESCRIPTI0N=WR1TING. By I Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia. Illustrated. Cloth, $1.25 net. 

SURGICAL ASEPSIS. By CARL BECK, M.D., Surgeon to St. Mark's Hospital and 
to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
delphia. Illustrated. Cloth, $1.50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M I >. , 
Professor of Skin and Venereal Diseases, and Prank II. MONTGOMERY, M.D., 
Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, 
Chicago. Profusely illustrated. (Double number.) Cloth, $2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M.D.; Professor of 
Practice in the Woman's Medical College of the New York Infirmary; Instructor in 
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
(Double number.) Cloth, $2.50 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
University, etc. Beautifully illustrated. (Double Number.) Cloth, $2.50 net. 

MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, 
#2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to 
Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E. 
Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
London. Handsomely illustrated. (Double number.) Cloth, #2.50 net. 



VOLUMES IN PREPARATION. 

NOSE AND THROAT. By D. Braden Kyle, M.D., Chief Laryngologist to the St. 
Agnes Hospital, Philadelphia ; Bacteriologist to the Orthopaedic Hospital and Infirmary 
for Nervous Diseases; Instructor in Clinical Microscopy and Assistant Demonstrator of 
Pathology in the Jefferson Medical College, etc. 

NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopedic 
Hospital and Infirmary for Nervous Diseases : Visiting Physician to the St. Joseph 
Hospital, etc. 

*#* There will be published in the same series, at short intervals, carefully-prepared works 
on various subjects by prominent specialists. 



Pamphlet containing specimen pages, etc. sent free upon application* 



24 Medical Publications of W. B. Saunders. 

SAUNDBY'S RENAL AND URINARY DISEASES. 

Lectures on Renal and Urinary Diseases. By Robert Saundby, 
M.D. Edin., Fellow of the Royal College of Physicians, London, and 
of the Royal Medico-Chirurgical Society ; Physician to the General 
Hospital ; Consulting Physician to the Eye Hospital and to the Hos- 
pital for Diseases of Women; Professor of Medicine in Mason College, 
Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
trations and 4 colored plates. Cloth, $2.50 net. 

" The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended.' ' — British Medical Journal. 

SAUNDERS' POCKET MEDICAL FORMULARY. Fourth Edition, 
Revised. 

By William M. Powell, M.D., Attending Physician to the Mercer 
House for Invalid Women at Atlantic City, N. J. Containing 1750 
formulae selected from the best-known authorities. With an Appen- 
dix containing Posological Table, Formulae and Doses for Hypo- 
dermic Medication, Poisons and their Antidotes, Diameters of the 
Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various 
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in flexible morocco, with side index, wallet, and flap. 

$i-75 net - 

" This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and, as the name of the author of each prescription 
is given, is unusually reliable." — Medical Record, New York. 

SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition, 
Revised. 
A Dictionary of Terms and Words used in Medicine and 
Surgery. By John M. Keating, M.D., Fellow of the College of 
Physicians of Philadelphia; Editor of the ''Cyclopaedia of Diseases 
of Children," etc.; Author of the "New Pronouncing Dictionary of 
Medicine;" and Henry Hamilton, Author of "A New Translation 
of Virgil's ^Eneid into English Verse;" Co-Author of the "New 
Pronouncing Dictionary of Medicine." 321110, 280 pages. Cloth, 
75 cents; Leather Tucks, $1.00. 

" Remarkably accurate in terminology, accentuation, and definition." — Journal of the 

American Medical Association. 

SAYRE'S PHARMACY. Second Edition, Revised. 

Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
M.D., Professor of Pharmacy and Materia Medica in the University of 
Kansas. Crown octavo, 200 pages. Cloth, |i.oo; interleaved for 
notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

" The topics are treated in a simple, practical manner, and the work forms a very useful 
student's manual." — Boston Medical and Surgical Journal. 



Medical Publications of W. B. Saunders. 26 



SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
Essentials of Legal Medicine, Toxicology, and Hygiene. By 
C. E. Armand SEMPLE, 13. A., M. B. Cantab., M. R. C. P. Lond., 
Physician to the Northeastern Hospital for Children, Hackney, etc. 
Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00; interleaved 
for notes, $1.25. 

[See Saunders Question- Compends, page 21.] 

" No general practitioner or student can afford to be without this valuable work. The 
subjects are dealt with by a masterly hand." — London Hospital Gazette. 

SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 

Essentials of Pathology and Morbid Anatomy.- By C. E. 

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 
174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. 
[See Saunders' Question- Compends, page 21.] 

" Should take its place among the standard volumes on the bookshelf of both student 
and practitioner." — London Hospital Gazette. 

SENN'S GENITOURINARY TUBERCULOSIS. 

Tuberculosis of the Genito-Urinary Organs, Male and Female. 

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. 

" An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

" A work which adds another to the many obligations the profession owes the talented 
author." — Chicago Medical Recorder. 

SENN'S SYLLABUS OF SURGERY. 

A Syllabus of Lectures on the Practice of Surgery, arranged 
in conformity with •« An American Text=Book of Surgery." By 

Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and 
of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. 

" This syllabus will be found of service by the teacher as well as the student, the work 
being superbly done. There is no praise too high for it. No surgeon should be without 
it." — New York Medical Times. 

SENN'S TUMORS. 

Pathology and Surgical Treatment of Tumors. By N. Senn, 

M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. 
Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 
engravings, including full-page colored plates. Cloth, $6.00 net; 
Half Morocco, $7.00 net. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, and the author has given a 
notable and lasting contribution to surgery." — Jownal of the American Medical Association. 



26 Medical Publications of W. B. Saunders. 

SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
Revised. 
Essentials of Nervous Diseases and Insanity. By John C. 
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
System, Long Island College Hospital Medical School ; Consulting 
Neurologist to St. Catherine's Hospital and to the Long Island College 
Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, 
$1.00 ; interleaved for notes, $1.25. 

[See Saunders 1 Question- Comp ends, page 21.] 
"Clearly and intelligently written." — Boston Medical and Surgical Journal. 

"There is a mass of valuable material crowded into this small compass." — American 
Medico- Surgical Bulletin. 

STARR'S DIETS FOR INFANTS AND CHILDREN. 

Diets for Infants and Children in Health and in Disease. By 

Louis Starr, M.D., Editor of "An American Text-Book of the 
Diseases of Children." 230 blanks (pocket-book size), perforated 
and neatly bound in flexible morocco. $1.25 net. 

The first series of blanks are prepared for the first seven months of infant life ; each 
blank indicates the ingredients, but not the quantities, of the food, the latter directions being 
left for the physician. After the seventh month, modifications being less necessary, the diet 
lists are printed in full. Formulae for the preparation of diluents and foods are appended. 

STELW AGON'S DISEASES OF THE SKIN. Third Edition, Revised. 
Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
M.D., Clinical Professor of Dermatology in the Jefferson Medical 
College, Philadelphia; Dermatologist to the Philadelphia Hospital; 
Physician to the Skin Department of the Howard Hospital, etc. 
Crown octavo, 270 pages; 86 illustrations. Cloth, $1. 00 net; inter- 
leaved for notes, $1.25 net. 

[See Saitnders* Question- Compends, page 21.] 
" The best student's manual on skin diseases we have yet seen." — Times and Register. 

STENGEL'S PATHOLOGY. 

A Manual of Pathology. By Alfred Stengel, M.D., Physician 
to the Philadelphia Hospital ; Professor of Clinical Medicine in the 
Woman's Medical College; Physician to the Children's Hospital; 
late Pathologist to the German Hospital, Philadelphia, etc. In 
Preparation. 

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
Edition, Revised. 
A Manual of Materia Medica and Therapeutics. By A. A. 

Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
Physical Diagnosis in the University of Pennsylvania; Demonstrator 
of Pathology in the Woman's Medical College of Philadelphia. Post- 
octavo, 445 pages. Cloth, $2.25. 

"The author has faithfully presented modern therapeutics in a comprehensive work, 
and, while intended particularly for the use of students, it will be found a reliable guide and 
sufficiently comprehensive for the physician in practice." — University Medical Magazine. 



Medical Publications of W. B. Saunders. '27 

STEVENS' PRACTICE OF MEDICINE. Fourth Edition, Revised. 
A Manual of the Practice of Medicine. By A. A. S; , A.M., 

M.D., Lecturer on Terminology and Instructor in Physical Diagnosis 
in the University of Pennsylvania ; Demonstrator of Pathology in 
the Woman's Medical College of Philadelphia. .Specially intended 
for students preparing for graduation and hospital examinations. Post- 
octavo, 511 pages; illustrated. Cloth, $2.50. 

"The frequency with which new editions of tin's manual are demanded bespeaks its 
popularity. It is an excellent condensation of the essentials of medical practice lor the 
student, and maybe found also an excellent reminder for the busy physician." — Jiujfalo 
Medical Journal. 

STEWART'S PHYSIOLOGY. 

A Manual of Physiology, with Practical Exercises. For 
Students and Practitioners. By G. N. Stewart, M.A., Ml), 
D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
of the New Museums, Cambridge University ; Professor of Physiology 
in the Western Reserve University, Cleveland, Ohio. Octavo volume 
of 800 pages; 278 illustrations in the text, and 5 colored plates. 
Cloth, $3.50 net. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one 
of the very best English text-books on the subject." — London Lancet. 

"Of the many text-books of physiology published, we do not know of one that so 
nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. 

STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 

Essentials of Medical Electricity. By D. D. Stewart, M.D., 
Demonstrator of Diseases of the Nervous System and Chief of the 
Neurological Clinic in the Jefferson Medical College ; and E. S. 
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
strator of Diseases of the Nervous System in the Jefferson Medical 
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
$1.00 ; interleaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

" Throughout the whole brief space at their command the authors show a discriminating 
knowledge of their subject." — Medical News. 

STONEY'S NURSING. Second Edition, Revised. 

Practical Points in Nursing. For Nurses in Private Practice. 

By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
Lawrence, Mass.; late Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
with 73 engravings in the text, and 8 colored and half-tone plates. 

Cloth, $1.75 net. 

" There are few books intended for non-professional readers which can be so cordially 
endorsed by a medical journal as can this one." — Therapeutic Gazette. 

" This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise, and how to prepare everything ordinarily 
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
Women and Children. 

" It is a work that the physician can place in the hands of his private nurses with the 
assurance of benefit.' 1 — Ohio Medical Journal. 



28 Medical Publications of W. B. Saunders. 

SUTTON AND GILES' DISEASES OF WOMEN. 

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., 
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
somely illustrated. Cloth, $2.50 net. 

"The book is very well prepared, and is certain to be well received by the medical 
public. " — British Medical Journal. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day." — Journal of the 
American Medical Association. 

THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 

Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
M.D., Visiting Physician to the Home for Friendless Women and 
Children and to the Newsboys' Home ; Assistant Visiting Physician 
to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. 

" The idea is good, and the lists are copious." — London Lancet. 

"Its practical usefulness places it among the requirements of every practitioner." — 
Chicago Medical Recorder. 

THORNTONS DOSE=BOOK AND PRESCRIPTION=WRITING. 

Dose=Book and Manual of Prescription=Writing. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. 

"Full of practical suggestions; will take its place in the front rank of works of this 
sort." — Medical Record, New York. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
Diseases of the Stomach. By William W. Van Valzah, M.D., 
Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic ; and J. Douglas Nisbet, M.D., 
Adjunct Professor of General Medicine and Diseases of the Digestive 
System and the Blood, New York Polyclinic. Octavo volume of about 
600 pages. Cloth, $3.50 net. Nearly Ready. 

VIERORDT'S MEDICAL DIAGNOSIS. Third Edition, Revised. 
Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
cine at the University of Heidelberg. Translated, with additions, 
from the second enlarged German edition, with the author's permission, 
by Francis H. Stuart, A.M., M.D. Handsome royal octavo volume 
of 700 pages; 178 fine wood-cuts in text, many of them in colors. 
Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net; Half Russia, 
£5.50 net. 

" A treasury of practical information which will be found of daily use to every busy 
practitioner who will consult it." — C. A. Lindsley, M.D., Professor of the Theory and 
Practice of Medicine, Yale University. 

*" Rarely is a book published with which a reviewer can find so little fault as with the 
volume before us. Each particular item in the consideration of an organ or apparatus, which 
is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing 
seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
nervous system are especially full and valuable. The reviewer would repeat that the book is 
one of the best — probably the best — which has fallen into his hands." — University Medical 
Magazine. 



Medical Publications of W. B. Saunders. 2!> 



WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. 
Surgical Pathology and Therapeutics. By John ( Iollins W \i 

M.D., LL.D., Professor of Surgery, Medical Department Harvard 
University; Surgeon to the Massachusetts General Hospital, etc. 
Handsome octavo volume of 832 pages; 136 relief and lithographic 
illustrations, 33 of which are printed in colors, and all of which were 
drawn by William J. Kaula from original specimens. Cloth, $6.00 
net; Half Morocco, $7.00 net. 

"There is the work of Dr. -Warren, which I think is the most creditable book on 
Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that 
has ever been issued from the American press." — Dr. Roswell Park, in the Harvard 
Graduate Magazine. 

" The handsomest specimen of bookmaking that has ever been issued from the American 
medical press." — American Journal of the Medical Sciences. 

" A most striking and very excellent feature of this book is its illustrations. Without 
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
and detail as almost to give the beholder the impression that he is looking down the barrel 
of a microscope at a well-mounted section." — Annals of Surgery. 

WESTS NURSING. 

An American Text=Book of Nursing. By American Teachers. 
Edited by Roberta M. West, late Superintendent of Nurses in the 
Hospital of the University of Pennsylvania. In Preparation. 

WOLFF ON EXAMINATION OF URINE. 

Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, 
etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
octavo. Cloth, 75 cents. 

[See Saunders'' Question- Compends, page 21.] 
" A very good work of its kind — very well suited to its purpose." — Times and Register. 

WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised. 

Essentials of Medical Chemistry, Organic and Inorganic. 

Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
Philadelphia, etc. Crown octavo, 218 pages. Cloth, $1. 00; inter- 
leaved for notes, $1.25. 

[See Saunders' Question- Compends, page 21.] 

' ' The scope of this work is certainly equal to that of the best course of lectures on 
Medical Chemistry. " — Pharmaceutical Era. 



CLASSIFIED LIST 



Medical Publications 



OF 



W. B. SAUNDERS, 

925 Walnut Street, Philadelphia. 



ANATOMY, EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A Text-Book of Histology, 9 
Haynes — A Manual of Anatomy, ... 13 
Heisler — A Text-Book of Embryology, 13 
Nancrede — Essentials of Anatomy, . . 18 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, ... 18 
Semple — Essentials of Pathology and 

Morbid Anatomy 25 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, ... 6 
Crookshank — A Text-Book of Bacteri- 
ology, 10 

Frothingham — Laboratory Guide, . . II 
Mallory and Wright — Pathological 

Technique, 16 

McFarland — Pathogenic Bacteria, . . 17 

CHARTS, DIET=LISTS, ETC. 

Griffith — Infant's Weight Chart, ... 12 

Hart — Diet in Sickness and in Health, . 13 

Keen — Operation Blank, 15 

Laine — Temperature Chart, 15 

Meigs — Feeding in Early Infancy, . . 17 

Starr — Diets for Infants and Children, . 26 
Thomas — Diet-Lists and Sick-Room 

Dietary, 28 

CHEMISTRY AND PHYSICS. 

Brockway — Essentials of Medical Phys- 
ics, 7 

Wolff — Essentials of Medical Chemistry, 29 

CHILDREN. 

An American Text-Book of Diseases 

of Children, 3 

Griffith — Care of the Baby, 12 

Griffith — Infant's Weight Chart, ... 12 

Meigs — Feeding in Early Infancy, . . 17 

Powell — Essentials of Dis. of Children, 19 

Starr — Diets for Infants and Children, . 26 

DIAGNOSIS. 

Cohen and Eshner— Essentials of Di- 
agnosis, • 9 

Corwin — Physical Diagnosis, .... 9 

Macdonald — Surgical Diagnosis and 
Treatment, 16 

Vierordt— Medical Diagnosis, .... 28 

DICTIONARIES. 

Keating — Pronouncing Dictionary, . . 14 

Morten— Nurse's Dictionary, .... 18 

Saunders' Pocket Medical Lexicon, . 24 



EYE, EAR, NOSE, AND THROAT. 

An American Text-Book of Diseases 

of the Eye, Ear, Nose, and Throat, . 3 
Casselberry — Dis. of Nose and Throat, 8 
De Schweinitz — Diseases of the Eye, 10 
Gleason — Essentials of Dis. of the Ear, 11 
Jackson and Gleason — Essentials of 

Diseases of the Eye, Nose, and Throat, 14 
Kyle — Diseases of the Nose and Throat, 15 

GENITOURINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 3 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 13 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 16 

Saundby — Renal and Urinary Diseases, 24 

Senn — Genito-Urinary Tuberculosis, . 25 

GYNECOLOGY. 

American Text- Book of Gynecology, 4 
Cragin — Essentials of Gynecology, . . 10 
Garrigues — Diseases of Women, ... 11 
Long — Syllabus of Gynecology, ... 15 
Penrose — Diseases of Women, .... 18 
Sutton and Giles — Diseases of Women, 28 

MATERIA MEDICA, PHARMACOL- 
OGY, AND THERAPEUTICS. 

An American Text-Book of Applied 

Therapeutics, 3 

Butler — Text-Book of Materia Medica, 

Therapeutics and Pharmacology, ... 8 

Cerna — Notes on the Newer Remedies, 8 

Griffin — Materia Med. and Therapeutics, 12 

Morris — Essentials of Materia Medica 

and Therapeutics, ... .... 17 

Saunders' Pocket Medical Formulary, 24 
Sayre — Essentials of Pharmacy, ... 24 
Stevens — Essentials of Materia Medica 

and Therapeutics, 26 

Thornton — Dose-Book and Manual of 

Prescription-Writing, 28 

Warren — Surgical Pathology and Ther- 
apeutics, 29 

MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

An American Text-Book of Legal 
Medicine and Toxicology, 4 

Chapman — Medical Jurisprudence and 
Toxicology, 8 

Semple — Essentials of Legal Medicine, 
Toxicology, and Hygiene, 25 



Medical Publications of W. B. Saunders. 



31 



NERVOUS AND MENTAL 
DISEASES, ETC. 

Burr — Nervous Diseases, 7 

Chapin— Compendium of Insanity, . . 8 
Church and Peterson — Nervous and 

Mental Diseases, 9 

Shaw — Essentials of Nervous Diseases 

and Insanity, 26 

NURSING. 

An American Text-Book of Nursing, 29 

Griffith — The Care of the Baby, ... 12 

Hampton — Nursing, 12 

Hart — Diet in Sickness and in Health, 13 

Meigs — Feeding in Early Infancy, . . 17 

Morten — Nurse's Dictionary, .... 18 

Stoney — Practical Points in Nursing, . 27 

OBSTETRICS. 

An American Text-Book of Obstetrics, 4 
Ashton — Essentials of Obstetrics, ... 6 
Boisliniere — Obstetric Accidents, Emer- 
gencies, and Operations, 7 

Dorland — Manual of Obstetrics, . . . Io 

Hirst — Text-Book of Obstetrics, ... 13 

Norris — Syllabus of Obstetrics, .... 18 

PATHOLOGY. 

An American Text-Book of Pathology, 4 
Mallory and Wright — Pathological 

Technique, 16 

Semple — Essentials of Pathology and 

Morbid Anatomy, 25 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 25 

Stengel — Manual of Pathology, ... 26 
Warren — Surgical Pathology and Thera- 
peutics, 29 

PHYSIOLOGY. 

An American Text-Book of Physi- 

dogy, 5 

Hare — Essentials of Physiology, ... 13 

Raymond — Manual of Physiology, . . 19 

Stewart — Manual of Physiology, ... 27 

PRACTICE OF MEDICINE. 

An American Text-Book of the The- 
ory and Practice of Medicine, .... 5 

An American Year-Book of Medicine 
and Surgery, 6 

Anders — Text-Book of the Practice of 
Medicine, 6 

Lockwood — Manual of the Practice of 
Medicine, . . 15 

Morris — Essentials of the Practice of 
Medicine, ... 1 7 

Rowland and Hedley — Archives of 
the Roentgen Ray, 1 9 

Stevens — Manual of the Practice of 
Medicine, 27 

SKIN AND VENEREAL. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 3 



Hyde and Montgomery— Syphilid and 
the Venereal I )iseases, 1 1 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 16 

Pringle — Pictorial Atlas of Skin Dis- 
eases and Syphilitic Affections, ... 19 

Stelwagon — Essentials of Diseases of 
the Skin, 26 

SURGERY. 

An American Text-Book of Surgery, 5 
An American Year-Book of Medicine 

and Surgery, 6 

Beck — Manual of Surgical Asepsis, . . 7 
DaCosta — Manual of Surgery, .... 10 

Keen— Operation Blank, 15 

Keen — The Surgical Complications and 

Sequels of Typhoid Fever, 15 

Macdonald — Surgical Diagnosis and 

Treatment, 16 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . 16 
Martin — Essentials of Surgery, .... 16 

Moore — Orthopedic Surgery, 17 

Pye — Elementary Bandaging and Surgi- 
cal Dressing, 19 

Rowland and Hedley— Archives of 

the Roentgen Ray, 19 

Senn — Genito-Urinary Tuberculosis, . 25 

Senn — Syllabus of Surgery, 25 

Senn — Pathology and Surgical Treat- 
ment of Tumors, . 25 

Warren — Surgical Pathology and Ther- 
apeutics, 29 

URINE AND URINARY DISEASES. 

Saundby — Renal and Urinary Diseases, 24 
Wolff — Essentials of Examination of 
Urine, 29 

MISCELLANEOUS. 

Bastin — Laboratory Exercises in Bot- 
any, 7 

Gould and Pyle — Anomalies and Curi- 
osities of Medicine, n 

Gross — Autobiography of Samuel D. 
Gross, 12 

Keating — How to Examine for Life 
Insurance, 14 

Keen — Surgical Complications and Se- 
quels of Typhoid Fever, 15 

Rowland and Hedley — Archives of 
the Roentgen Ray, 19 

Saunders' New Series of Manuals, 22, 23 

Saunders' Pocket Medical Formulary, . 24 

Saunders' Question-Compends, . . 20, 21 

Senn — Pathology and Surgical Treat- 
ment of Tumors, .25 

Stewart and Lawrance — Essentials of 
Medical Electricity, 27 

Thornton — Dose-Book and Manual of 
Prescription-Writing, 28 

Van Valzah and Nisbet — Diseases of 
the Stomach, 28 



In Preparation for Early Publication, 



AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, 
AND THROAT. 

Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jeffer- 
son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor 
of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia 
Polyclinic. 

AN AMERICAN TEXT-BOOK OF PATHOLOGY. 

Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid 
Anatomy in the University of Pennsylvania ; and David Riesman, M. D. , Demon- 
strator of Pathological Histology in the University of Pennsylvania. 

PETERSON AND HAINES' LEGAL MEDICINE AND TOXICOLOGY. 

An American Text=Book of Legal Medicine and Toxicology. Edited by 
Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman's 
Medical College, New York ; Chief of Clinic, Nervous Department, College of 
Physicians and Surgeons, New York ; and Walter S. Haines, M.D., Professor of 
Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago. 

STENGEL'S PATHOLOGY. 

A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Phila- 
delphia Hospital ; Professor of Clinical Medicine in the Woman's Medical Col- 
lege; Physician to the Children's Hospital; late Pathologist to the German Hospital, 
Philadelphia, etc. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 

Nervous and Mental Diseases. By Archibald Church, M.D., Professor of 
Mental Diseases and Medical Jurisprudence in the Northwestern University Medical 
School, Chicago ; and Frederick Peterson, M.D. , Clinical Professor of Mental 
Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous 
Department, College of Physicians and Surgeons, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Professor of 
Anatomy in the Medico-Chirurgical College, Philadelphia. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D. , Chief 
Laryngologist to St. Agnes' Hospital ; Bacteriologist to the Orthopedic Hospital and 
Infirmary for Nervous Diseases ; Instructor in Clinical Microscopy and Assistant 
Demonstrator of Pathology, Jefferson Medical College, Philadelphia. 

HIRST'S OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of 
Obstetrics in the University of Pennsylvania. 

WEST'S NURSING. 

An American Text=Book of Nursing. By American Teachers. Edited by 
Roberta M. West, Late Superintendent of Nurses in the Hospital of the University 
of Pennsylvania. 



